Kentucky Administrative Regulations › Title 900 - CABINET FOR HEALTH AND FAMILY SERVICES › Chapter 10 - Kentucky Health Benefit Exchange › Section 900 KAR 10:111 - Definitions for 900 KAR Chapter 10

Current through Register Vol. 51, No. 1, July 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
(b) Located at
https://www.qhpcertification.cms.gov/s/QHP
.
(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.