Kentucky Statutes 304.17B-015 – Eligibility for coverage under Kentucky Access
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(1) Any individual who is an eligible individual and a resident of Kentucky is eligible for coverage under Kentucky Access, except as specified in paragraphs (a), (b), (d), and (e) of subsection (4) of this section.
(2) Any individual who is not an eligible individual who has been a resident of the Commonwealth for at least twelve (12) months immediately preceding the application for Kentucky Access coverage is eligible for coverage under Kentucky Access if one (1) of the following conditions is met:
(a) The individual has been rejected by at least one (1) insurer for coverage of a health benefit plan that is substantially similar to Kentucky Access coverage;
(b) The individual has been offered coverage substantially similar to Kentucky Access coverage at a premium rate greater than the Kentucky Access premium rate at the time of enrollment or upon renewal; or
(c) The individual has a high-cost condition listed in KRS § 304.17B-001.
(3) A Kentucky Access enrollee whose premium rates exceed claims for a three (3) year period shall be issued a notice of insurability. The notice shall indicate that the Kentucky Access enrollee has not had claims exceed premium rates for a three (3) year period and may be used by the enrollee to obtain insurance in the regular individual market.
(4) An individual shall not be eligible for coverage under Kentucky Access if:
(a) 1. The individual has, or is eligible for, on the effective date of coverage under Kentucky Access, substantially similar coverage under another contract or policy, unless the individual was issued coverage from a GAP participating insurer as a GAP qualified individual prior to January
1, 2001. A GAP qualified individual shall be automatically eligible for coverage under Kentucky Access without regard to the requirements of subsection (2) of this section; or
2. For individuals meeting the requirements of KRS § 304.17A-005(11), the individual has, or is eligible for, on the effective date of coverage under Kentucky Access, coverage under a group health plan.
An individual who is ineligible for coverage pursuant to this paragraph shall not preclude the individual’s spouse or dependents from being eligible for Kentucky Access coverage. As used in this paragraph, “eligible for” includes any individual and an individual’s spouse or dependent who was eligible for coverage but waived that coverage. That individual and the individual’s spouse or dependent shall be ineligible for Kentucky Access coverage through the period of waived coverage;
(b) The individual is eligible for coverage under Medicaid or Medicare;
(c) The individual previously terminated Kentucky Access coverage and twelve (12) months have not elapsed since the coverage was terminated, unless the individual demonstrates a good faith reason for the termination;
(d) Except for covered benefits paid under the standard health benefit plan as
specified in KRS § 304.17B-019, Kentucky Access has paid two million dollars ($2,000,000) in covered benefits per individual. The maximum limit under this paragraph may be increased by the office;
(e) The individual is confined to a public institution or incarcerated in a federal, state, or local penal institution or in the custody of federal, state, or local law enforcement authorities, including work release programs; or
(f) The individual’s premium, deductible, coinsurance, or copayment is partially or entirely paid or reimbursed by an individual or entity other than the individual or the individual’s parent, grandparent, spouse, child, stepchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, sibling, brother-in- law, sister-in-law, grandchild, guardian, or court-appointed payor.
(5) The coverage of any person who ceases to meet the requirements of this section or the requirements of any administrative regulation promulgated under this subtitle may be terminated.
Effective: June 27, 2019
History: Amended 2019 Ky. Acts ch. 90, sec. 18, effective June 27, 2019. — Amended
2010 Ky. Acts ch. 24, sec. 1280, effective July 15, 2010; and ch. 126, sec. 1, effective July 15, 2010. — Amended 2002 Ky. Acts ch. 351, sec. 8, effective July 15,
2002. — Created 2000 Ky. Acts ch. 476, sec. 8, effective July 14, 2000.
(2) Any individual who is not an eligible individual who has been a resident of the Commonwealth for at least twelve (12) months immediately preceding the application for Kentucky Access coverage is eligible for coverage under Kentucky Access if one (1) of the following conditions is met:
Terms Used In Kentucky Statutes 304.17B-015
- Contract: A legal written agreement that becomes binding when signed.
- Dependent: A person dependent for support upon another.
- Enrollee: means a person who is enrolled in a health benefit plan offered under
Kentucky Access. See Kentucky Statutes 304.17B-001 - Federal: refers to the United States. See Kentucky Statutes 446.010
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- High-cost condition: means acquired immune deficiency syndrome (AIDS), angina pectoris, ascites, chemical dependency, cirrhosis of the liver, coronary insufficiency, coronary occlusion, cystic fibrosis, Friedreich's ataxia, hemophilia, Hodgkin's disease, Huntington's chorea, juvenile diabetes, leukemia, metastatic cancer, motor or sensory aphasia, multiple sclerosis, muscular dystrophy, myasthenia gravis, myotonia, open-heart surgery, Parkinson's disease, polycystic kidney, psychotic disorders, quadriplegia, stroke, syringomyelia, Wilson's disease, chronic renal failure, malignant neoplasm of the trachea, malignant neoplasm of the bronchus, malignant neoplasm of the lung, malignant neoplasm of the colon, short gestation period for a newborn child, and low birth weight of a newborn child. See Kentucky Statutes 304.17B-001
- Medicaid: means coverage in accordance with Title XIX of the Social Security
Act, 42 U. See Kentucky Statutes 304.17B-001 - Medicare: means coverage under both Parts A and B of Title XVIII of the Social
Security Act, 42 U. See Kentucky Statutes 304.17B-001 - Office: means the Office of Health Data and Analytics in the Cabinet for Health and Family Services. See Kentucky Statutes 304.17B-001
- State: when applied to a part of the United States, includes territories, outlying possessions, and the District of Columbia. See Kentucky Statutes 446.010
- Year: means calendar year. See Kentucky Statutes 446.010
(a) The individual has been rejected by at least one (1) insurer for coverage of a health benefit plan that is substantially similar to Kentucky Access coverage;
(b) The individual has been offered coverage substantially similar to Kentucky Access coverage at a premium rate greater than the Kentucky Access premium rate at the time of enrollment or upon renewal; or
(c) The individual has a high-cost condition listed in KRS § 304.17B-001.
(3) A Kentucky Access enrollee whose premium rates exceed claims for a three (3) year period shall be issued a notice of insurability. The notice shall indicate that the Kentucky Access enrollee has not had claims exceed premium rates for a three (3) year period and may be used by the enrollee to obtain insurance in the regular individual market.
(4) An individual shall not be eligible for coverage under Kentucky Access if:
(a) 1. The individual has, or is eligible for, on the effective date of coverage under Kentucky Access, substantially similar coverage under another contract or policy, unless the individual was issued coverage from a GAP participating insurer as a GAP qualified individual prior to January
1, 2001. A GAP qualified individual shall be automatically eligible for coverage under Kentucky Access without regard to the requirements of subsection (2) of this section; or
2. For individuals meeting the requirements of KRS § 304.17A-005(11), the individual has, or is eligible for, on the effective date of coverage under Kentucky Access, coverage under a group health plan.
An individual who is ineligible for coverage pursuant to this paragraph shall not preclude the individual’s spouse or dependents from being eligible for Kentucky Access coverage. As used in this paragraph, “eligible for” includes any individual and an individual’s spouse or dependent who was eligible for coverage but waived that coverage. That individual and the individual’s spouse or dependent shall be ineligible for Kentucky Access coverage through the period of waived coverage;
(b) The individual is eligible for coverage under Medicaid or Medicare;
(c) The individual previously terminated Kentucky Access coverage and twelve (12) months have not elapsed since the coverage was terminated, unless the individual demonstrates a good faith reason for the termination;
(d) Except for covered benefits paid under the standard health benefit plan as
specified in KRS § 304.17B-019, Kentucky Access has paid two million dollars ($2,000,000) in covered benefits per individual. The maximum limit under this paragraph may be increased by the office;
(e) The individual is confined to a public institution or incarcerated in a federal, state, or local penal institution or in the custody of federal, state, or local law enforcement authorities, including work release programs; or
(f) The individual’s premium, deductible, coinsurance, or copayment is partially or entirely paid or reimbursed by an individual or entity other than the individual or the individual’s parent, grandparent, spouse, child, stepchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, sibling, brother-in- law, sister-in-law, grandchild, guardian, or court-appointed payor.
(5) The coverage of any person who ceases to meet the requirements of this section or the requirements of any administrative regulation promulgated under this subtitle may be terminated.
Effective: June 27, 2019
History: Amended 2019 Ky. Acts ch. 90, sec. 18, effective June 27, 2019. — Amended
2010 Ky. Acts ch. 24, sec. 1280, effective July 15, 2010; and ch. 126, sec. 1, effective July 15, 2010. — Amended 2002 Ky. Acts ch. 351, sec. 8, effective July 15,
2002. — Created 2000 Ky. Acts ch. 476, sec. 8, effective July 14, 2000.