Kentucky Administrative Regulations › Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE › Chapter 17 - Health Insurance Contracts › Section 806 KAR 17:570E - Minimum standards for Medicare supplement insurance policies and certificates

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				304.2-310,
				304.2-320,
				304.3-240,
				304.12-020,
				304.14-120,
				304.14-500-304.14-550,
				304.17-311,
				304.17A-005,
				304.18-034,
				304.32-275,
				304.33-030,
				304.38-205, 42. C.F.R. 409.87,
				45 C.F.R. Part 46,
				74 F.R. 18808 (2009),
				29 U.S.C.
				1002,
				42 U.S.C.
				426,
				42 U.S.C.
				1320c-3,
				1320d,
				1320d-2,
				42 U.S.C.
				1395-1395gg g,
				42 U.S.C.
				1396,
				Pub. L.
				114-10, 108-173, 116-127, 117-328
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				304.2-110(1) authorizes the
				commissioner of the Department of Insurance to promulgate administrative
				regulations necessary for or as an aid to the effectuation of any provision of
				the Kentucky Insurance Code, as defined in
				KRS
				304.1-010.
				KRS
				304.14-510 authorizes the commissioner of the
				Department of Insurance to promulgate administrative regulations establishing
				minimum standards for Medicare supplement insurance policies.
				KRS
				304.32-250 authorizes the commissioner of the
				Department of Insurance to promulgate administrative regulations necessary for
				the proper administration of
				KRS
				304.32.
				KRS
				304.38-150 authorizes the commissioner of the
				Department of Insurance to promulgate administrative regulations necessary for
				the proper administration of KRS Chapter 304.38. This administrative regulation
				establishes minimum standards for Medicare supplement insurance policies and
				certificates.
Section 1. Definitions.
(1) "Applicant" is defined by
			 KRS
			 304.14-500(1).
(2) "Bankruptcy" means a petition for
			 declaration of bankruptcy filed by or filed against a Medicare Advantage
			 organization that is not an insurer and has ceased doing business in the
			 state.
(3) "Certificate" is defined
			 by KRS
			 304.14-500(2).
(4) "Certificate form" means the form on
			 which the certificate is delivered or issued for delivery by the
			 insurer.
(5) "Commissioner" means
			 Commissioner of the Department of Insurance.
(6) "Compensation" means monetary or
			 non-monetary remuneration of any kind relating to the sale or renewal of the
			 policy or certificate including bonuses, gifts, prizes, awards, and finder's
			 fees.
(7) "Complaint" means any
			 dissatisfaction expressed by an individual concerning a Medicare Select insurer
			 or its network providers.
(8)
			 "Continuous period of creditable coverage" means the period during which an
			 individual was covered by creditable coverage, if during the period of the
			 coverage the individual had no breaks in coverage greater than sixty-three (63)
			 days.
(9) "Creditable coverage" is
			 defined by KRS
			 304.17A-005(8).
(10) "Employee welfare benefit plan" means a
			 plan, fund, or program of employee benefits as defined in
			 29 U.S.C. Section
			 1002 of the Employee Retirement Income
			 Security Act.
(11) "Family member"
			 means, with respect to an individual, any other individual who is a
			 first-degree, second-degree, third-degree, or fourth-degree relative of the
			 individual.
(12) "Genetic
			 information" means except for information relating to the sex or age:
(a) With respect to any individual:
1. Information about the individual's genetic
			 tests, the genetic tests of family members of the individual, and the
			 manifestation of a disease or disorder in family members of the individual;
			 or
2. Any request for, or receipt
			 of, genetic services, or participation in clinical research which includes
			 genetic services, by the individual or any family member of the
			 individual.
(b) Any
			 reference to genetic information concerning an individual or family member of
			 an individual who is a pregnant woman, including:
1. Genetic information of any fetus carried
			 by a pregnant woman; or
2. With
			 respect to an individual or family member utilizing reproductive technology,
			 genetic information of any embryo legally held by an individual or family
			 member.
(13)
			 "Genetic services" means a genetic test, genetic counseling (including
			 obtaining, interpreting, or assessing genetic information), or genetic
			 education.
(14) "Genetic test":
(a) Means an analysis of human DNA, RNA,
			 chromosomes, proteins, or metabolites, that detect genotypes, mutations, or
			 chromosomal changes;
(b) Except for
			 an analysis of proteins or metabolites that does not detect genotypes,
			 mutations, or chromosomal changes; or an analysis of proteins or metabolites
			 that is directly related to a manifested disease, disorder, or pathological
			 condition that may reasonably be detected by a health care professional with
			 appropriate training and expertise in the field of medicine involved.
(15) "Grievance" means
			 dissatisfaction expressed in writing by an individual insured under a Medicare
			 Select policy or certificate with the administration, claims practices, or
			 provision of services concerning a Medicare Select insurer or its network
			 providers.
(16) "Health care
			 expenses" means expenses of health maintenance organizations associated with
			 the delivery of health care services, which expenses are analogous to incurred
			 losses of insurers.
(17)
			 "Insolvency" is defined by
			 KRS
			 304.33-030(12).
(18) "Insurer" means insurance companies,
			 fraternal benefit societies, health care service plans, health maintenance
			 organizations, and any other entity delivering or issuing for delivery in this
			 state Medicare supplement policies or certificates.
(19) "Insurer of a Medicare supplement policy
			 or certificate" means an insurer or third-party administrator, or other person
			 acting for or on behalf of the insurer.
(20) "Medicare" is defined by
			 KRS
			 304.14-500(4).
(21) "Medicare Advantage plan" means a plan
			 of coverage for health benefits under Medicare Part C as defined in
			 42 U.S.C.
			 1395w-28(b)(1), including:
(a) A coordinated care plan, which provides
			 health care services, including the following:
1. A health maintenance organization plan,
			 with or without a point-of-service option;
2. A plan offered by provider-sponsored
			 organization; and
3. A preferred
			 provider organization plan;
(b) A medical savings account plan coupled
			 with a contribution into a Medicare Advantage plan medical savings account;
			 and
(c) A Medicare Advantage
			 private fee-for-service plan.
(22) "Medicare Select insurer" means an
			 insurer offering, or seeking to offer, a Medicare Select policy or
			 certificate.
(23) "Medicare Select
			 policy" or "Medicare Select certificate" means, respectively, a Medicare
			 supplement policy or certificate that contains restricted network
			 provisions.
(24) "Medicare
			 supplement policy" is defined by
			 KRS
			 304.14-500(3).
(25) "Network provider" means a provider of
			 health care, or a group of providers of health care, that has entered into a
			 written agreement with the insurer to provide benefits insured under a Medicare
			 Select policy.
(26) "Policy form"
			 means the form on which the policy is delivered or issued for delivery by the
			 insurer.
(27) "Pre-Standardized
			 Medicare supplement benefit plan," "Pre-Standardized benefit plan," or
			 "Pre-Standardized plan" means a group or individual policy of Medicare
			 supplement insurance issued prior to January 1, 1992.
(28) "Restricted network provision" means any
			 provision that conditions the payment of benefits, in whole or in part, on the
			 use of network providers.
(29)
			 "Secretary" means the Secretary of the U.S. Department of Health and Human
			 Services.
(30) "Service area" means
			 the geographic area approved by the commissioner within which an insurer is
			 authorized to offer a Medicare Select policy.
(31) "Structure, language, designation, and
			 format" means style, arrangement, and overall content of a benefit.
(32) "Underwriting purposes" means:
(a) Rules for, or determination of,
			 eligibility, including enrollment and continued eligibility, for benefits under
			 the policy;
(b) The computation of
			 premium or contribution amounts under the policy;
(c) The application of any pre-existing
			 condition exclusion under the policy; and
(d) Other activities related to the creation,
			 renewal, or replacement of a contract of health insurance or health
			 benefits.
(33) "1990
			 Standardized Medicare supplement benefit plan," "1990 Standardized benefit
			 plan," or "1990 plan" means a group or individual policy of Medicare supplement
			 insurance issued on or after January 1, 1992, with an effective date for
			 coverage prior to June 1, 2010 including Medicare supplement insurance policies
			 and certificates renewed on or after that date that are not replaced by the
			 insurer at the request of the insured.
(34) "2010 Standardized Medicare supplement
			 benefit plan," "2010 Standardized benefit plan," or "2010 plan" means a group
			 or individual policy of Medicare supplement insurance issued with an effective
			 date for coverage on or after June 1, 2010.