806 KAR 17:260. Conversion policy minimum benefits

Section 1. Definitions. (1) "Conversion policy" means an individual health policy issued to an insured person pursuant to a conversion privilege contained in a group health policy upon termination of the insured person's coverage under the group policy. (2) "FFS" means a fee-for-service product type. (3) "Group policy" is defined by KRS 304.18-110(1)(a). (4) "HMO" means a health maintenance organization product type. (5) "POS" means a point-of-service product type. (6) "PPO" means a preferred provider organization product type. (7) "Preventive Health Service" means the service described by 29 C.F.R 2590.715-2713(a) and (b). Section 2. Plan Cost Sharing and Minimum Benefits. (1) The out-of-pocket limit for covered expenses incurred during a plan year for a converted policy issued pursuant to a conversion privilege contained in a PPO, FFS, HMO, or POS product shall be no more than: (a) $7,000 for a single person; and (b) $14,000 for a family. (2) A converted policy issued pursuant to the conversion privilege contained in a group HMO, POS, FFS, or PPO product shall include the following minimum benefits: (a) In hospital care: 1. Inpatient hospital room and board benefits in a maximum coinsurance amount of fifty (50) percent; and 2. Coverage benefits in a maximum coinsurance amount of fifty (50) percent for transplants, including: a. Kidney; b. Cornea; c. Bone marrow; d. Heart; e. Liver; f. Lung; g. Heart orlung; and h. Pancreas. (b) Outpatient care: 1. Ambulatory outpatient surgery benefits in a maximum coinsurance amount of fifty (50) percent; 2. Provider office visits benefits in a maximum coinsurance amount of fifty (50) percent; and 3. Diagnostic tests and Laboratory benefits in a maximum coinsurance amount of fifty (50) percent; (c) Emergency care: 1. Hospital emergency room benefits in a maximum coinsurance amount of fifty (50) percent; and 2. Ground ambulance benefits in a maximum coinsurance amount of fifty (50) percent. (d) Medicare hospice benefits. (e) Prescription drug benefits in a maximum coinsurance amount of fifty (50) percent. (f) Maternity Benefits in a maximum coinsurance amount of fifty (50) percent. (g) Mental Health and Substance Abuse Benefits: 1. Inpatient Benefits in a maximum coinsurance amount of fifty (50) percent; and 2. Outpatient Benefits in a maximum coinsurance amount of fifty (50) percent. (h) Rehabilitative and Habilitative Benefits in a maximum coinsurance amount of fifty (50) percent. (i) Preventive Health Service shall be covered at 100 percent. (j) Pediatric Benefits in a maximum coinsurance amount of fifty (50) percent.