806 KAR 17:540. ICARE Program high-cost conditions

      Section 1. Definitions. (1) "Eligible employee" is defined in 2012 Ky. Acts ch. 144, Part XII, sec. 1(3).

      (2) "High-cost condition" is defined in 2012 Ky. Acts ch. 144, Part XII, sec. 1(5).

      (3) "ICARE Program" means the Insurance Coverage, Affordability and Relief to Small Employers Program as established in 2012 Ky. Acts ch. 144, Part XII, sec. 2(1).

 

      Section 2. List of High-Cost Conditions. An ICARE Program high-cost condition shall:

      (1) Be diagnosed or treated by a health care provider legally authorized to diagnose the condition within the past five (5) years and documented in the medical record of an eligible employee; and

      (2) Include one (1) of the following medical conditions:

      (a) Anoxic brain injury, which shall be limited to anoxic brain injury associated with:

      1. Drowning and nonfatal submersion; or

      2. Intrauterine hypoxia and birth asphyxia;

      (b) Ascites;

      (c) Back disorder, which shall be limited to:

      1. Lumbar or Lumbosacral disc degeneration; or

      2. Lumbar disc displacement;

      (d) Brain tumor;

      (e) Burn, which shall be limited to full-thickness skin loss involving ten (10) percent or more of body surface;

      (f) Cancer, which shall be limited to:

      1. Ewing’s sarcoma;

      2. Hodgkin’s disease;

      3. Leukemia;

      4. Lymphoid leukemia;

      5. Malignant neoplasm of breast;

      6. Metastatic cancer;

      7. Myeloid leukemia; or

      8. Primary cancer;

      (g) Cirrhosis of the liver;

      (h) Endocrine disorder, which shall be limited to:

      1    Insulin dependent diabetes mellitus; or

      2. Enzyme deficiency disorder which shall be limited to inborn errors of metabolism;

      (i) Heart condition, which shall be limited to:

      1. Acute myocardial infarction;

      2. Angina pectoris;

      3. Cardiac valve disorder;

      4. Cardiomyopathy;

      5. Congenital cardiac anomaly;

      6. Coronary insufficiency;

      7. Coronary occlusion;

      8. Heart failure;

      9. Injury to heart or lung;

      10. Ischemic heart disease;

      11. Pulmonary atresia;

      12. Pulmonary hypertension; or

      13. Status post open-heart surgery;

      (j) Hemophilia;

      (k) Hypersomnia with sleep apnea;

      (l) Lung condition, which shall be limited to:

      1. Chronic airway obstruction;

      2. Disease of the lung; or

      3. Post inflammatory pulmonary fibrosis;

      (m) Kidney condition, which shall be limited to:

      1. Chronic renal failure;

      2. End stage renal disease; or

      3. Polycystic kidney;

      (n) Morbid obesity;

      (o) Multiple sclerosis;

      (p) Organ or tissue replaced by transplant;

      (q) Psychotic disorder;

      (r) Rhabdomyolysis;

      (s) Stroke; or

      (t) Trauma, which shall be limited to:

      1. Fracture or complete lesion of cord; or

      2. Multiple trauma. (33 Ky.R. 1471; 1841; eff. 3-9-2007; 35 Ky.R. 667; eff. 1-5-2009; 37 Ky.R. 502; eff. 11-5-2010; 39 Ky.R. 615; eff. 12-7-2012.)

Notation

      RELATES TO: 2012 Ky. Acts ch. 144, Part XII, secs. 1-8,12

      STATUTORY AUTHORITY: KRS 304.2-110(1), 2012 Ky. Acts ch. 144, Part XII, sec. 2(3)(b)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) authorizes the Commissioner of Insurance to promulgate administrative regulations necessary for or as an aid to the effectuation of any provisions of the Kentucky Insurance Code as defined in KRS 304.1-010. 2012 Ky. Acts ch. 144, Part XII, sec. 2(3)(b) requires the department to establish by administrative regulation a list of high-cost conditions for the ICARE Program. This administrative regulation establishes a list of high-cost conditions representing the top twenty (20) high-cost conditions in the small group market.