Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO: KRS Chapter 45A, Chapter 304, 304.2-310,
29 U.S.C.
794,
42 U.S.C.
12101-12103,
18022,
18031,
18042,
18054, 45
C.F.R. Part 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 registration of an
individual agent and certification of a kynector, including a certified
application counselor or navigator in accordance with
42 U.S.C.
18031 and 45 C.F.R. Part 155 .
Section 1. KHBE Consumer Assistance Programs.
(1) The kynector program, in accordance with
the accessibility standards of
45 C.F.R.
155.205(c) and (d), shall
include the following:
(a) The certified
application counselor program described in Section 2 of this administrative
regulation; and
(b) The navigator
program described in Section 3 of this administrative regulation.
(2) A kynector shall:
(a) Receive training in accordance with
45
C.F.R. 155.215(b)(2) that
shall be provided by the division or an approved vendor;
(b) Complete Medicaid, KCHIP, and other
applicable training provided by CHFS;
(c) Complete all training required by the
division within three (3) attempts;
(d) Enter into an agreement with the division
to comply with the applicable standards of
45 C.F.R.
155.205,
155.210,
155.215,
and
155.225
and this administrative regulation;
(e) Refer a consumer to other consumer
assistance programs and community resources in Kentucky if available and
appropriate;
(f) Be prepared to
serve the individual exchange, Medicaid program, KCHIP, and other programs as
designated by the secretary of CHFS; and
(g) Comply with the privacy and security
standards consistent with
45
C.F.R. 155.260.
Section 2. Certified Application
Counselor Program.
(1) The certified
application counselor program shall comply with the provisions of
45 C.F.R.
155.225.
(2) An organization shall apply to the
division to be designated as a certified application counselor.
(3) Upon designation by the division to
participate in the certified application counselor program, an organization
shall:
(a) Act in the best interest of an
applicant;
(b) Provide information
in a manner that is accessible to individuals with disabilities directly or
through a referral to a kynector; and
(c) Provide quarterly reports of an activity
to the division.
(4) A
staff or a volunteer of a certified application counselor organization shall
act as a kynector to:
(a) Provide information
about an insurance affordability program and a QHP or SADP coverage
option;
(b) Assist an individual to
apply through the KHBE for coverage in a QHP, SADP, or an insurance
affordability program; and
(c) Help
to facilitate enrollment of a qualified individual in a QHP, SADP, or an
insurance affordability program.
(5) An individual operating as a certified
application counselor shall:
(a) Be identified
by a designated organization described in subsection (2) of this section as an
employee or a volunteer of the designated organization;
(b) Agree to act in the best interest of an
applicant;
(c) Provide information
with reasonable accommodation for an individual with a disability, as defined
by
42 U.S.C.
12101 through
12103, if
providing in-person assistance; and
(d) Register with the division through the
KOG.
(6) A certified
application counselor shall not:
(a) Impose
any charge or fee on an applicant for application assistance;
(b) Receive compensation or a referral fee
from an agent; or
(c) Enter into an
exclusive referral agreement with an agent.
(7) In accordance with the procedures
established in Section 4 of this administrative regulation, the division shall
withdraw certification from a kynector or kynector entity if it finds
non-compliance with the terms and conditions of the kynector or kynector entity
agreement or this administrative regulation.
Section 3. Navigator Program.
(1) In accordance with
45 C.F.R.
155.205(d) and (e),
155.210,
and
155.215,
the division shall establish a navigator program to authorize an eligible
public or private entity to carry out consumer assistance functions as
described in
45 C.F.R.
155.205 and this section.
(2) An entity wishing to participate as a
navigator shall:
(a) Be awarded a contract by
the division pursuant to policies and procedures established by the Finance and
Administration Cabinet and KRS Chapter 45A;
(b) Designate an individual as the
participating entity representative who shall:
1. Register with the division through the KOG
as the individual authorized by the agency;
2. Serve as a primary contact for the
division;
3. Be responsible for
ensuring that only an employee of the navigator agency is registered through
KOG as a certified navigator;
4.
Comply with
45 C.F.R.
155.210(b)(1) and (d)
regarding a conflict of interest; and
5. As a navigator employee, comply with this
subsection;
(c)
Designate an individual employee who shall participate through the navigator
entity and who shall register with the division through the KOG;
(d) Submit to the division a written plan to
remain free of conflicts of interest while carrying out consumer assistance
functions under
45 C.F.R.
155.205(d) and (e), and
155.210;
and
(e) Provide a monthly report of
activities to the division.
(3) An employee designated as a navigator by
the kynector entity shall:
(a) Be eighteen
(18) years of age or older;
(b)
Provide an authorization to the navigator entity to conduct a state background
check for evidence of good character; and
(c) Travel, if necessary, to assist an
applicant with enrollment.
(4) A navigator entity and its employees
shall:
(a) Inform an applicant of the
functions and responsibilities of a navigator and a participating
agent;
(b) Obtain authorization for
the disclosure of applicant information prior to assisting an applicant with
prescreening and completion of the application process; and
(c) Provide technical support to another
navigator, navigator entity, or the division upon request.
(5) Upon authorization by the division, a
navigator may assist:
(a) A qualified
individual with enrollment in any QHP or SADP offered though the KHBE in the
individual market;
(b) A small
employer with applying for an eligibility determination online to participate
on SHOP; or
(c) An individual with
applying for insurance affordability programs, including Medicaid or KCHIP, and
other public assistance programs as designated by KHBE.
(6) A navigator entity and its employees
shall:
(a) Maintain expertise in eligibility,
enrollment, and program specifications and conduct public education activities
to raise awareness about a QHP, SADP, or an insurance affordability program;
and
(b) Provide information and
services in a fair, accurate, and impartial manner.
(7) A navigator entity and its employees
shall not:
(a) Impose any charge or fee on an
applicant for their assistance;
(b)
Receive compensation or a referral fee from an agent; or
(c) Enter into an exclusive referral
agreement with an agent.
(8) A navigator entity and its employees
shall provide information in a manner that is culturally and linguistically
appropriate to the needs of the population being served by the exchange,
including individuals with limited English proficiency, and ensure
accessibility and usability of navigator tools and functions for individuals
with disabilities in accordance with the Americans with Disabilities Act,
42 U.S.C.
12101, Section
504 of the
Rehabilitation Act, and
29 U.S.C.
794.
(9) A navigator entity or its employees shall
provide a referral to the DOI for any enrollee or qualified individual with a
grievance, complaint, or question regarding a health plan, coverage, or a
determination under the plan or coverage.
(10) A navigator entity or its employees
shall demonstrate to the division that the entity has existing relationships,
or could readily establish relationships, with:
(a) Consumers, including uninsured and
underinsured consumers; or
(b)
Self-employed individuals eligible for a QHP, SADP, or another insurance
affordability program.
(11)
(a) In
accordance with Section 4 of this administrative regulation, the division shall
withdraw certification if it finds noncompliance with the terms and conditions
of the agreement from:
1. An individual
navigator; or
2. A navigator
entity.
(b) In addition
to withdrawal of certification, the division may enforce any penalty as
specified in the contract.
Section 4. Withdrawal of Certification of a
kynector and Appeals.
(1) If the division
finds noncompliance with the terms and conditions of an agreement or this
administrative regulation, the division shall:
(a) Provide the kynector entity or kynector
with notice that the applicable certification shall be withdrawn as of the date
on the notice;
(b) Allow the
kynector entity or kynector an opportunity to submit evidence of compliance or
additional information within ten (10) business days;
(c) Review any information submitted by the
kynector entity or kynector; and
(d) Based on a review of the information
provided, issue a final decision to withdraw or reinstate the applicable
certification of the kynector entity or kynector.
(2) A kynector entity or kynector may appeal
a final decision to withdraw the applicable certification by submitting a
written request to the division within ten (10) business days of the final
decision.
(3) After one (1) year
following a decision to withdraw certification of a kynector entity or
kynector, the kynector or kynector entity may reapply in accordance with this
administrative regulation.
Section
5. Requirements to be a Participating Individual Agent. An agent
wishing to participate on KHBE in accordance with
42 U.S.C.
18031 and
45
C.F.R. 155.220 shall:
(1) Be licensed by DOI with a health line of
authority;
(2) Complete the agent
training provided by the division in accordance with
45
C.F.R. 155.220(d)(2) within
three (3) attempts;
(3) Enter into
an agreement with the division to comply with the applicable standards of
45 C.F.R.
155.205 and
155.220
and this administrative regulation;
(4) Comply with the privacy and security
standards of
45
C.F.R. 155.260;
(5) Except for an employee of an issuer or an
individual agent directly contracted with an issuer, maintain:
(a) An appointment with at least one (1) QHP
or SADP issuer participating on the KHBE; or
(b) A designation with a business entity
having an appointment with at least one (1) QHP or SADP issuer participating on
the KHBE;
(6) Register
with the KHBE through the KOG; and
(7) Not serve as a web broker or consultant
while assisting individuals with the activities described in Section 6 of this
administrative regulation.
Section
6. Permitted Activities of a Participating Individual Agent.
(1) Upon completion of the registration
requirements as set forth in Section 5 of this administrative regulation, a
participating individual agent may:
(a) Enroll
a qualified individual in any QHP or SADP offered by an issuer with which the
individual agent has the appropriate designation or appointment as required by
Section 5(5) of this administrative regulation through the KHBE in the
individual market;
(b) Assist a
qualified employer in selecting a QHP or SADP offered by an issuer with which
the individual agent has the appropriate designation or appointment as required
by Section 5(5) of this administrative regulation; or
(c) Assist an individual to apply through the
KHBE for coverage in a QHP, SADP, or an insurance affordability
program.
(2) A qualified
individual may be enrolled in a QHP or SADP through the KHBE by a participating
individual agent if the participating individual agent ensures the applicant's
completion of an application as described in
45 C.F.R.
155.405.
(3) A participating individual agent shall:
(a) Disclose to a potential applicant any
relationships the individual agent has with a QHP or SADP issuer, insurance
affordability program, or other potential conflicts of interest identified by
the division; and
(b) Not:
1. Impose any charge or fee on an applicant
for assistance in completing an application for, or enrolling in, a QHP, a
SADP, or an insurance affordability program;
2. Provide compensation or a referral fee to
a kynector; and
3. Enter into an
exclusive referral agreement with a kynector.
(4) If the division finds noncompliance with
this administrative regulation, the division shall withdraw an agent's
registration and participation with the KHBE after giving:
(a) Notice to the participating individual
agent; and
(b) An opportunity to
respond to the notice required by paragraph (a) of this subsection in
accordance with Section 8 of this administrative regulation.
Section 7. Renewal of
Participation and Registration with the Division. To maintain registration with
the division, a participating individual agent shall:
(1) Comply with training provided by the
division;
(2) Enter into an
agreement with the division to comply with the applicable standards of
45 C.F.R.
155.205 and
155.220
and this administrative regulation;
(3) Maintain licensure, appointments, and
designations as identified in Section 5 of this administrative
regulation;
(4) Comply with the
requirements of
45
C.F.R. 155.220; and
(5) Comply with 900 KAR Chapter 10.
Section 8. Withdrawal of
Registration as an Individual Agent and Appeals.
(1)
(a)
Except as established in subsection (2) of this section, if the division finds
noncompliance with the terms and conditions of an individual agent agreement or
900 KAR Chapter 10, the division shall:
1.
Provide the participating individual agent with notice that the applicable
registration shall be withdrawn as of the date of notice;
2. Allow the participating individual agent
an opportunity to submit evidence of compliance or additional information
within ten (10) business days;
3.
Review any information submitted by the participating individual agent;
and
4. Based on a review of the
information provided, issue a decision to uphold the withdrawal or reinstate
the applicable registration of a participating individual agent.
(b) A participating individual
agent shall have the right to appeal a decision to withdraw registration in
accordance with paragraph (a) of this subsection through the
division.
(2)
(a) If the health line of authority or
licensure of an agent is suspended, revoked, or expired, the registration of
the agent shall be withdrawn by the division based on DOI's administrative
action.
(b) Any appeal or request
of an action by DOI pursuant to paragraph (a) of this subsection shall be made
to DOI in accordance with
KRS
304.2-310(2)(b).
(3) After one (1) year following a
decision to withdraw the registration of a participating individual agent, the
individual agent may reapply in accordance with Section 5 of this
administrative regulation.
STATUTORY AUTHORITY:
KRS
194A.050(1)