Kentucky Administrative Regulations › Title 900 - CABINET FOR HEALTH AND FAMILY SERVICES › Chapter 10 - Kentucky Health Benefit Exchange › Section 900 KAR 10:115 - Exchange participation requirements and certification of qualified health plans and qualified stand-alone dental plans

Current through Register Vol. 51, No. 1, July 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.