900 KAR 10:030. Kentucky Health Benefit Exchange eligibility and enrollment in a qualified health plan

     Section 1. Definitions. (1) "Advance payments of the premium tax credit" or "APTC" means payment of the tax credits authorized by 26 U.S.C. 36B and its implementing regulations, which are 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.

     (2) "Affordable Care Act" or "ACA" means the Patient Protection and Affordable Care Act, Public Law 111-148, enacted March 23, 2010, as amended by the Health Care and Education Reconciliation Act, Public Law 111-152, enacted March 30, 2010.

     (3) "Annual open enrollment period" is defined by 45 C.F.R. 155.410(e).

     (4) "Applicant" is defined by 45 C.F.R. 155.20.

     (5) "Application filer" is defined by 45 C.F.R. 155.20.

     (6) "Benefit year" means a calendar year for which a health plan provides coverage for health benefits.

     (7) "Catastrophic plan" means a health plan that is described in and meets the requirements of 45 C.F.R. 156.155.

     (8) "COBRA" means continuation of coverage under 29 U.S.C. Part 6.

     (9) "Cost sharing" is defined by 45 C.F.R. 155.20.

     (10) "Cost-sharing reduction" or "CSR" means a reduction in cost sharing for an eligible individual enrolled in a silver level plan in an exchange or for an individual who is an Indian enrolled in a qualified health plan in an exchange.

     (11) "Date of the notice" means the date on the notice plus five (5) calendar days.

     (12) "Department of Health and Human Services" or "HHS" means the U.S. Department of Health and Human Services.

     (13) "Dependent" is defined by 26 C.F.R. 54.9801-2.

     (14) "Enrollee" means a qualified individual enrolled in a qualified health plan.

     (15) "Family size" is defined by 26 C.F.R. 1.36B-1(d).

     (16) "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.

     (17) "Health plan" is defined by 42 U.S.C. 18021(b)(1).

     (18) "Household income" is defined by 26 C.F.R. 1.36B-1(e).

     (19) "Indian" is defined by 25 U.S.C. 450b(d).

     (20) "Initial open enrollment period" means the period beginning October 1, 2013, and extending through March 31, 2014, during which a qualified individual or qualified employee may enroll in health coverage through an exchange for the 2014 benefit year.

     (21) "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 established under section 36B of the Internal Revenue Code, 26 U.S.C. 36B, available to qualified individuals; or

     (d) A program that makes available coverage in a qualified health plan through the exchange with cost-sharing reductions established under section 1402 of the Affordable Care Act, 42 U.S.C. 18071.

     (22) "Issuer" is defined by 45 C.F.R. 144.103.

     (23) "Kentucky Children’s Health Insurance Program" or "KCHIP" means the separate child health program established by the Commonwealth of Kentucky under title XXI of the Social Security Act in accordance with implementing regulations at 42 C.F.R. 457.

     (24) "Kentucky Health Benefit Exchange" or "KHBE" means the Kentucky state-based exchange conditionally approved by HHS pursuant to 45 C.F.R. 155.105 to offer a QHP beginning January 1, 2014, that includes an:

     (a) Individual exchange; and

     (b) Small Business Health Options Program.

     (25) "Lawfully present" is defined by 45 C.F.R. 155.20.

     (26) "Medicaid" means coverage in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq. as amended.

     (27) "Minimum essential coverage" is defined by 26 U.S.C. 5000A-2.

     (28) "Non-citizen" is defined by 45 C.F.R. 155.300.

     (29) "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.

     (30) "Public insurance program" means an insurance program that:

     (a) Is paid for by a governmental entity and provided to consumers; and

     (b) Includes Medicare, Medicaid, or Children’s Health Insurance Program.

     (31) "Qualified Health Plan" or "QHP" means a health plan that meets the standards described in 45 C.F.R. 156 Subpart C and that has in effect a certification issued by the office.

     (32) "Qualified individual" is defined by 45 C.F.R. 155.20.

     (33) "Qualifying coverage in an eligible employer-sponsored plan" means coverage in an eligible employer-sponsored plan that meets the affordability and minimum value standards specified in 26 U.S.C. 36B(c)(2)(C).

     (34) "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.

     (35) "Silver level" is defined by 42 U.S.C. 18022(d)(1)(B).

     (36) "Special enrollment period" means a period 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 initial and annual open enrollment periods.

     (37) "Tax filer" is defined by 45 C.F.R. 155.300.

 

     Section 2. Eligibility Standards to Enroll in a Qualified Health Plan. (1) An applicant shall be eligible to enroll in a QHP through the KHBE if the applicant:

     (a) 1. Is a citizen or national of the United States;

     2. Is a non-citizen who is lawfully present in the United States and is reasonably expected to become a citizen or national; or

     3. Is a non-citizen who is lawfully present for the entire period for which enrollment is sought;

     (b) Except for an incarceration pending a disposition of a charge, is not incarcerated; and

     (c) Meets a residency requirement in 45 C.F.R. 155.305(a)(3).

     (2) An applicant may submit an application as described in 45 C.F.R. 155.405 for a determination of eligibility at any time during a year; however, the applicant shall only enroll during an open enrollment or special enrollment period.

     (3) An applicant determined eligible for enrollment in a QHP as set forth in subsection (1) of this section shall be eligible to enroll in a QHP during:

     (a) An annual open enrollment period as set forth in Section 6(1) of this administrative regulation; or

     (b) A special enrollment period as set forth in Section 7 of this administrative regulation.

     (4) An applicant determined eligible to enroll in a QHP who does not select a QHP within the applicable enrollment period as set forth in Sections 6 or 7 or is not eligible for an enrollment period, who seeks a new enrollment period prior to the date on which the applicant’s eligibility is redetermined as set forth in Section 9 of this administrative regulation, shall attest to whether or not information affecting the applicant’s eligibility has changed since the most recent eligibility determination.

     (5) An applicant shall submit an application for enrollment in a QHP:

     (a) Via the KHBE Web site at www.kynect.ky.gov;

     (b) By telephone by contacting the KHBE contact center at 1-800-459-6328;

     (c) By mail; or

     (d) In person.

     (6)(a) An applicant who has a Social Security number shall provide the number to the KHBE.

     (b) An individual who is not seeking coverage for himself or herself shall not be required to provide a Social Security number, except as specified in Section 3(8) of this administrative regulation.

     (7) In accordance with 45 C.F.R. 155.310(a)(2), an individual who is not seeking coverage for himself or herself on any application or any supplemental form shall not be required to provide information regarding:

     (a) Citizenship;

     (b) Status as a national; or

     (c) Immigration status.

     (8)(a) Except as specified in Section 11(2) of this administrative regulation, an applicant who requests an eligibility determination for an insurance affordability program shall have an eligibility determination for all insurance affordability programs.

     (b) An applicant who requests an eligibility determination for a QHP only shall not have an eligibility determination for an insurance affordability program.

     (9) An applicant shall not provide information beyond the minimum amount necessary to determine eligibility and enrollment through the KHBE.

     (10) If an application filer submits an application that does not include sufficient information for the KHBE to make an eligibility determination for enrollment in a QHP or for an insurance affordability program, the KHBE shall:

     (a) Provide notice to the applicant that additional information is needed to complete an eligibility determination;

     (b) Provide the applicant with a period of ninety (90) days to provide the requested information;

     (c) Not proceed with an applicant’s eligibility determination or provide APTC or CSR until the information is received; and

     (d) Consider the application null and void if the requested information is not received within ninety (90) days.

 

     Section 3. Eligibility Standards for Advanced Payments of the Premium Tax Credit. (1) A tax filer shall be eligible for APTC if:

     (a) The tax filer is expected to have a household income greater than or equal to 100 percent of the FPL but not more than 400 percent of the FPL for the benefit year for which coverage is requested; and

     (b) One (1) or more applicants for whom the tax filer expects to claim a personal exemption deduction on the tax filer’s tax return for the benefit year:

     1. Meets the requirements for eligibility for enrollment in a QHP through the KHBE as specified in Section 2 of this administrative regulation; and

     2. Is not eligible for minimum essential coverage, with the exception of coverage in the individual market, in accordance with 26 C.F.R. 1.36B-2(a)(2) and (c).

     (2) A tax filer who is a non-citizen and lawfully present and ineligible for Medicaid for reason of immigration status shall be eligible for APTC if:

     (a) The tax filer meets the requirement in subsection (1)(b) of this section;

     (b) The tax filer is expected to have a household income of less than 100 percent of the FPL for the benefit year for which coverage is requested; and

     (c) One (1) or more applicants for whom the tax filer expects to claim a personal exemption deduction on the tax filer’s tax return for the benefit year is:

     1. A non-citizen who is lawfully present; and

     2. Not eligible for Medicaid for reason of immigration status.

     (3) A tax filer shall attest that one (1) or more applicants for whom the tax filer attests that a personal exemption deduction for the benefit year shall be claimed is enrolled in a QHP that is not a catastrophic plan.

     (4) A tax filer shall not be eligible for APTC if HHS notifies the KHBE that APTCs were made on behalf of the tax filer or tax filer’s spouse for a year in accordance with 45 C.F.R. 155.305(f)(4).

     (5) An APTC amount shall be:

     (a) Calculated in accordance with 26 C.F.R. 1.36B-3; and

     (b) Allocated between QHPs and stand-alone dental policies in accordance with 45 C.F.R. 155.340(e).

     (6) An applicant for APTC may accept less than the full amount of APTC for which the applicant is determined eligible.

     (7) An APTC shall be authorized by the KHBE on behalf of a tax filer only if the KHBE obtains necessary attestations from the tax filer that:

     (a) The tax filer shall file an income tax return for the benefit year in accordance with 26 U.S.C. 6011 and 6012;

     (b) If the tax filer is married, a joint tax return shall be filed for the benefit year;

     (c) No other taxpayer shall be able to claim the tax filer as a dependent for the benefit year; and

     (d) The tax filer shall claim a personal exemption deduction on the tax filer’s return for the applicants identified as members of the tax filer’s family, including the tax filer and the spouse of the tax filer, in accordance with 45 C.F.R. 155.305(f)(4).

     (8) An application filer who is not an applicant shall provide the Social Security number of a tax filer only if the applicant attests that the tax filer:

     (a) Has a Social Security number; and

     (b) Filed a tax return for the year for which tax data would be utilized for verification of household income and family size.

     (9) The effective date of eligibility for APTC shall be:

     (a) For an initial eligibility determination, in accordance with the dates specified in Section 6 of this administrative regulation, as applicable; and

     (b) For a redetermination, in accordance with the dates specified in 45 C.F.R. 155.330(f) and 155.335(i), as applicable.

     (10) An employer shall be notified of an employee’s eligibility for APTC in accordance with 45 C.F.R. 155.310(h).

 

     Section 4. Eligibility Standards for Cost-sharing Reductions. (1) An applicant shall be eligible for cost-sharing reductions if the applicant:

     (a) Meets the eligibility requirements for enrollment in a QHP as set forth in Section 2 of this administrative regulation;

     (b) Meets the requirements for APTC as set forth in Section 3 of this administrative regulation;

     (c) Is expected to have a household income that does not exceed 250 percent of the FPL for the benefit year for which coverage is requested; and

     (d) Except for an enrollee who is an Indian and whose eligibility is governed by Section 11 of this administrative regulation, enrolls in a silver level QHP through the KHBE.

     (2) An eligibility determination for cost-sharing reductions shall be based on the following categories:

     (a) 1. An individual who is expected to have a household income greater than or equal to 100 percent of the FPL and less than or equal to 150 percent of the FPL for the benefit year for which coverage is requested; or

     2. An individual who is eligible for APTC as set forth in Section 3(2) of this administrative regulation, and who has a household income less than 100 percent of the FPL;

     (b) An individual who is expected to have a household income greater than 150 percent of the FPL and less than or equal to 200 percent of the FPL for the benefit year for which coverage is requested; and

     (c) An individual who is expected to have a household income greater than 200 percent of the FPL and less than or equal to 250 percent of the FPL for the benefit year for which coverage is requested.

     (3)(a) If two (2) or more individuals enrolled in the individual market under a single policy would be eligible for different cost sharing amounts if enrolled in separate policies, the individuals under the single policy shall be deemed by the KHBE to be collectively eligible only for the last category listed in paragraph (b) of this subsection for which all the individuals covered by the policy would be eligible.

     (b) The categories of eligibility shall be an individual:

     1. Not eligible for changes to cost sharing;

     2. Described in 45 C.F.R. 155.350(b);

     3. Described in subsection (2)(c) of this section;

     4. Described in subsection (2)(b) of this section;

     5. Described in subsection (2)(a) of this section; and

     6. Described in 45 C.F.R. 155.350(a).

     (4) The effective date of eligibility for cost-sharing reductions shall be:

     (a) For an initial eligibility determination, in accordance with the dates specified in Section 6 of this administrative regulation, as applicable; and

     (b) For a redetermination, in accordance with the dates specified in 45 C.F.R. 155.330(f) and 45 C.F.R. 155.335(i), as applicable.

     (5) An employer shall be notified of an employee’s eligibility for cost-sharing reductions in accordance with 45 C.F.R. 155.310(h).

 

     Section 5. Verification processes. (1) Verification of eligibility for an applicant seeking enrollment in a QHP shall be performed in accordance with:

     (a) 45 C.F.R. 155.315; and

     (b) Kentucky QHP/APTC Eligibility Verification Plan as incorporated by reference in this administrative regulation.

     (2) Verification of eligibility for an applicant or tax filer who requests an eligibility determination for an insurance affordability program shall be in accordance with:

     (a) 45 C.F.R. 155.320; and

     (b) Kentucky QHP/APTC Eligibility Verification Plan as incorporated by reference in this administrative regulation.

 

     Section 6. QHP Enrollment Periods and Effective Dates of Coverage. (1)(a) For a benefit year beginning on or after January 1, 2015, a qualified individual shall be able to enroll in a QHP, or an enrollee shall be able to change from one (1) QHP to another, during an annual open enrollment period set forth in 45 C.F.R. 155.410 for that benefit year.

     (b) The effective date of coverage for an enrollment or change of enrollment under paragraph (a) of this subsection shall be in accordance with 45 C.F.R. 155.335(i).

     (2)(a) A qualified individual shall enroll in a QHP or an enrollee shall change from one (1) QHP to another QHP during a special enrollment period as specified in Section 7 of this administrative regulation.

     (b) A qualified individual or an enrollee who selects a QHP during a special enrollment period shall have an effective date of coverage as set forth in Section 7 of this administrative regulation.

     (3) An initial enrollment in a QHP shall not be effective until the first month’s premium is received by the QHP issuer.

 

     Section 7. Special Enrollment Periods. (1) Except as specified in subsection (3) of this section, a qualified individual or enrollee shall have sixty (60) days from the date of a qualifying event as set forth in subsection (2) of this section to select a QHP.

     (2) A qualified individual may enroll in a QHP or an enrollee or a dependent of an enrollee may change QHPs during a special enrollment period if:

     (a) The qualified individual or a dependent of the qualified individual:

     1. Loses minimum essential coverage;

     2. Enrolled in any non-calendar year health insurance coverage, even if the qualified individual or a dependent of the qualified individual has the option to renew the expiring non-calendar year individual health insurance coverage;

     3. Loses pregnancy-related coverage described under 42 U.S.C.1396a (a)(10)(A)(i)(IV) and 42 U.S.C. 1396a(a)(10)(A)(ii)(IX); or

     4. Loses medically needy coverage as described under 42 U.S.C. 1396a(a)(10)(C) only once per calendar year;

     (b) The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement in foster care, or placement for adoption;

     (c) The qualified individual or dependent of the qualified individual, who was not previously a citizen, national, or lawfully present, gains status as a citizen, national, or lawfully present;

     (d) The qualified individual or dependent of the qualified individual enrolls or fails to enroll in a QHP due to an error, misrepresentation, or inaction of an officer, employee, or agent of the Kentucky Office of Health Benefit and Health Information Exchange or HHS;

     (e) The enrollee or dependent of the enrollee demonstrates to the KHBE that the QHP in which the enrollee or the dependent of the enrollee is enrolled substantially violated a provision of its contract in relation to the enrollee;

     (f) The enrollee is determined newly eligible or newly ineligible for APTC or has a change in eligibility for CSR;

     (g) The enrollee’s dependent enrolled in the same QHP is determined newly eligible or ineligible for APTC or has a change in eligibility for CSR;

     (h) The qualified individual or a dependent of the qualified individual who is enrolled in an employer-sponsored plan is determined newly eligible for APTC in part on a finding that the individual will no longer be eligible for qualifying coverage in the employer-sponsored plan in accordance with 26 C.F.R. 1.36B-2(c)(3) within the next sixty (60) days and is allowed to terminate existing coverage;

     (i) The qualified individual or enrollee or a dependent of the qualified individual or the enrollee gains access to new QHPs as a result of a change in residence;

     (j) The qualified individual is an Indian who may enroll in a QHP or change from one (1) QHP to another QHP one (1) time per month;

     (k) The qualified individual or a dependent of the qualified individual demonstrates to the Kentucky Office of Health Benefit and Health Information Exchange that the individual meets other exceptional circumstances; or

     (l) The Kentucky Office of Health Benefit and Health Information Exchange determines that as a result of misconduct on the part of a non-Kentucky Office of Health Benefit and Health Information Exchange entity providing enrollment assistance or conducting enrollment activities, a qualified individual or enrollee, or dependent of a qualified individual or enrollee:

     1. Was not enrolled in QHP coverage;

     2. Was not enrolled in the QHP selected by the qualified individual or enrollee; or

     3. Is eligible but is not receiving APTC or CSRs.

     (3) A qualified individual or enrollee, or a dependent of a qualified individual or enrollee described in subsection (2)(h) of this section may access this special enrollment period sixty (60) days prior to the end of the individual’s qualifying coverage in an eligible employer-sponsored plan.

     (4) The date of the triggering event for the loss of minimum essential coverage shall be:

     (a) For a decertification of a QHP as set forth in 900 KAR 10:010, the date of the notice of decertification;

     (b) For a loss of coverage as set forth in subsection (2)(a)1. of this section, the last day the qualified individual would have coverage under the qualified individual’s previous plan or coverage;

     (c) For a loss of coverage as set forth in subsection (2)(a)2. of this section, the date of the expiration of the non-calendar year policy;

     (d) For a loss of coverage as set forth in subsection (2)(a)3. of this section, the last day the qualified individual would have pregnancy-related coverage; or

     (e) For a loss of coverage as set forth in subsection (2)(a)4. of this section, the last day the qualified individual would have medically needy coverage.

     (5) Loss of minimum essential coverage shall include those circumstances described in 26 C.F.R. 54.9801–6(a)(3)(i) through (iii).

     (6) Loss of minimum essential coverage shall not include termination or loss due to:

     (a) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or

     (b) A situation allowing for a rescission as specified in 45 C.F.R. 147.128.

     (7) Except as specified in subsection (8) of this section, a qualified individual or enrollee who selects a QHP during a special enrollment period shall have an effective date of coverage of:

     (a) The first day of the following month for a selection made between the first and the fifteenth day of any month; or

     (b) The first day of the second following month for a selection made between the sixteenth and last day of any month.

     (8) A qualified individual or enrollee who selects a QHP during a special enrollment period:

     (a) For coverage following a birth, adoption, placement in foster care, or placement for an adoption shall have as the effective date of coverage:

     1. The date of the birth, adoption, placement in foster care, or placement for adoption; or

     2. If elected by the qualified individual or enrollee, the first day of the month following the date of birth, adoption, placement in foster care, or placement for adoption;

     (b) For coverage following a marriage shall have as the effective date of coverage the first day of the month following the selection of a QHP;

     (c) For coverage following a loss of coverage described in subsection (2)(a) or (2)(h) of this section, if the plan selection is made:

     1. Before or on the day of the loss of coverage, shall have as the effective date of coverage the first day of the month following the loss of coverage; or

     2. After the loss of coverage, shall have as the effective date of coverage the first day of the month following plan selection; or

     (d) For a special enrollment described in subsection (2)(d), (e), (k), or (l) of this section, shall have the effective date of coverage based on the circumstance of the special enrollment period.

     (9)(a) An individual described in subsection (2)(h) of this section may access a special enrollment period sixty (60) days prior to the end of the individual’s qualifying coverage in the employer-sponsored plan.

     (b) An individual described in subsection (2)(a) of this section shall have sixty (60) calendar days before and after the loss of coverage to select a QHP.

     (c) An individual who accesses a special enrollment as set forth in paragraph (a) or (b) of this subsection shall not be eligible for APTCs until the end of the individual’s qualifying coverage through the eligible employer-sponsored plan or loss of minimum essential coverage.

     (10) For a determination of eligibility for a special enrollment described in subsection (2)(d), (k), or (l) of this section, KHBE shall follow HHS guidance as set forth in:

     (a) Guidance for Issuers on Special Enrollment Periods for Complex Cases in the Federally-facilitated Marketplace after the Initial Open Enrollment Period and Special Enrollment Period, as incorporated by reference in this administrative regulation;

     (b) Guidance for Issuers on People "In Line" for the Federally-facilitated Marketplace at the end of the Initial Open Enrollment Period, as incorporated by reference in this administrative regulation; or

     (c) Special Enrollment Periods and Hardship Exemptions for Persons Meeting Certain Criteria, as incorporated by reference in this administrative regulation.

 

     Section 8. Eligibility Redetermination During a Benefit Year. (1) Eligibility shall be redetermined for an enrollee during a benefit year if the KHBE receives and verifies:

     (a) New information reported by an enrollee; or

     (b) Updated information obtained in accordance with 45 C.F.R. 155.315(b)(1) and 45 C.F.R. 155.320(b) that identifies:

     1. A death; or

     2. For an enrollee who is receiving APTCs or CSRs, a change in eligibility for a public insurance program.

     (2) Except as specified in subsection (3) of this section, an enrollee or an application filer, on behalf of an enrollee, shall report within thirty (30) days:

     (a) A change related to an eligibility standard in Section 2, 3, 4, 10, or 11 of this administrative regulation; and

     (b) Via a method described in Section 2(5) of this administrative regulation.

     (3) An enrollee who did not request an eligibility determination for an insurance affordability program shall not report a change related to income.

     (4) If new information provided by an enrollee in accordance with subsection (1)(a) of this section is verified:

     (a) Eligibility shall be redetermined in accordance with Section 2, 3, 4, 10, or 11 of this administrative regulation;

     (b) The enrollee shall be notified of the redetermination in accordance with the requirements in 45 C.F.R. 155.310(g); and

     (c) If applicable, the enrollee’s employer shall be notified in accordance with the requirement specified in 45 C.F.R. 155.310(h).

     (5) If updated information obtained in accordance with subsection (1)(b) of this section regarding death or related to eligibility not regarding income, family size, or family composition is identified, an enrollee shall:

     (a) Be notified by the KHBE of:

     1. The updated information; and

     2. The projected enrollee’s eligibility determination after consideration of the information; and

     (b) Have thirty (30) days from the date of the notice in paragraph (a) of this subsection to notify the KHBE if the information is inaccurate.

     (6) If an enrollee responds to the notice in subsection (5)(a) of this section, contesting the updated information in the notice, the KHBE shall proceed in accordance with 45 C.F.R. 155.315(f).

     (7) If an enrollee does not respond to the notice in subsection (5)(a) of this section within the thirty (30) day timeframe specified in subsection (5)(b) of this section, the KHBE shall:

     (a) Redetermine eligibility in accordance with Section 2, 3, 4, 10, or 11 of this administrative regulation; and

     (b) Notify the enrollee regarding the determination in accordance with the requirements specified in 45 C.F.R. 155.310(g).

     (8) With the exception of information regarding death, if updated information regarding income, family size, or family composition is identified, an enrollee shall:

     (a) Be notified by the KHBE of:

     1. The updated information regarding income, family size, and family composition obtained in accordance with subsection (1)(b) of this section; and

     2. The projected eligibility determination after consideration of the information; and

     (b) Have thirty (30) days from the date of the notice to:

     1. Confirm the updated information; or

     2. Provide additional information.

     (9) If the enrollee responds to the notice in subsection (8)(a) of this section by confirming the updated information, the KHBE shall:

     (a) Redetermine the enrollee’s eligibility in accordance with Section 2, 3, 4, 10, or 11 of this administrative regulation; and

     (b) Notify the enrollee regarding the determination in accordance with the requirements specified in 45 C.F.R. 155.310(g).

     (10) If the enrollee does not respond to the notice in subsection (8)(a) of this section within the thirty (30) day timeframe specified in subsection (8)(b) of the section, the KHBE shall maintain the enrollee’s existing eligibility determination without considering the updated information in subsection (8)(a) of this section.

     (11) If the enrollee responds with more updated information, the KHBE shall verify the updated information in accordance with 45 C.F.R. 155.315 and 155.320.

     (12) The effective date of a change resulting from a redetermination pursuant to this section shall be in accordance with 45 C.F.R. 155.330(f).

     (13) The amount of an APTC or eligibility for a cost-sharing reduction as a result of an eligibility redetermination in accordance with this section shall be recalculated in accordance with 45 C.F.R. 155.330(g).

 

     Section 9. Annual Eligibility Redetermination. (1) A qualified individual shall:

     (a) Have an annual redetermination of eligibility; and

     (b) Be sent a notice of the annual redetermination that includes:

     1. The qualified individual’s projected annual household income and family size; and

     2. The projected eligibility determination for the following year, after considering the information in subparagraph 1. of this paragraph.

     (2)(a) A qualified individual requesting an eligibility determination for an insurance affordability program shall authorize the release of updated tax return information for use in the qualified individual’s eligibility redetermination.

     (b) Eligibility shall not be redetermined for a qualified individual requesting an eligibility determination for an insurance affordability program who does not authorize the release of updated tax return information.

     (3) A qualified individual may authorize the release of tax return information for a period of no more than five (5) years based on a single authorization, if the authorization permits the qualified individual to:

     (a) 1. Decline to authorize the release of updated tax return information; or

     2. Authorize the release of updated tax return information for fewer than five (5) years; and

     (b) Discontinue, change, or renew the authorization at any time.

     (4) A qualified individual, an application filer, or an authorized representative, on behalf of the enrollee, shall report any changes with respect to the information listed in the notice described in subsection (1)(b) of this section:

     (a) Within thirty (30) days from the date of the notice; and

     (b) Via a method listed in Section 2(5) of this administrative regulation.

     (5) Any information reported by a qualified individual under subsection (4) of this section shall be verified as set forth in Section 5 of this administrative regulation.

     (6)

     (a) After the thirty (30) day period specified in subsection (4) of this section:

     1. Eligibility of a qualified individual shall be redetermined in accordance with Section 2, 3, 4, 10, or 11 of this administrative regulation using the information provided in the notice, as supplemented with any information reported by the qualified individual verified in accordance with Section 5 of this administrative regulation;

     2. The qualified individual shall be notified in accordance with the requirements in 45 C.F.R. 155.310(g); and

     3. If applicable, the qualified individual’s employer shall be notified in accordance with 45 C.F.R. 155.310(h).

     (b) If a qualified individual reports a change with respect to the information provided in the notice specified in subsection (1)(b) of this section that has not been verified by the KHBE as of the end of the thirty (30) day period specified in subsection (4) of this section, eligibility shall be redetermined after verification in accordance with Section 5 of this administrative regulation.

     (7) The effective date of a redetermination in accordance with this section shall be the later of:

     (a) The first day of the coverage year following the year in which the notice in subsection (1)(b) of this section is issued to the qualified individual; or

     (b) In accordance with 45 C.F.R. 155.330(f).

     (8) If an enrollee remains eligible for coverage in a QHP upon annual redetermination and has not terminated coverage from the QHP in accordance with Section 13 of this administrative regulation, the enrollee shall:

     (a) Remain in the QHP selected the previous year that may include modifications that shall be approved by the Department of Insurance; or

     (b) Be enrolled by KHBE in a QHP that is substantially similar that shall be approved by the Department of Insurance.

     (9) If an enrollee remains eligible for coverage in a QHP upon annual redetermination, the enrollee may change from one (1) QHP to another.

     (10) Eligibility shall not be redetermined if a qualified individual was redetermined eligible in accordance with this section during the prior year, and the qualified individual was not enrolled in a QHP at the time of the redetermination and has not enrolled in a QHP since the redetermination.

 

     Section 10. Eligibility to Enroll in a QHP that is a Catastrophic Plan. (1) In addition to the requirements in Section 2 of this administrative regulation, to enroll in a QHP that is a catastrophic plan, an applicant shall:

     (a) Not have attained the age of thirty (30) before the beginning of the plan year; or

     (b) Have a certificate of exemption from the shared responsibility payment issued by the KHBE or HHS for a plan year in accordance with:

     1. 26 U.S.C. 5000A(e)(1); or

     2. 26 U.S.C. 5000A(e)(5).

     (2) Verification related to eligibility for enrollment in a QHP that is a catastrophic plan shall be in accordance with 45 C.F.R. 155.315(j).

 

     Section 11. Special Eligibility Standards and Processes for Indians. (1) An applicant who is an Indian shall be eligible for the special cost-sharing described in section 1402(d)(2) of the ACA, 42 U.S.C. 18071, if the applicant:

     (a) Meets the requirements specified in 45 C.F.R. 155.305(a) and (f);

     (b) Is expected to have a household income that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested; and

     (c) Enrolls in a QHP through the KHBE.

     (2) An applicant who is an Indian shall have an eligibility determination for the special cost-sharing described in section 1402(d)(2) of the ACA, 42 U.S.C. 18071, without requesting an eligibility determination for an insurance affordability program.

 

     Section 12. Eligibility Determination and Notification Standards. (1) Eligibility shall be determined in accordance with 45 C.F.R. 155.310(e).

     (2) Notifications regarding eligibility determinations shall be made in accordance with 45 C.F.R. 155.310(g).

 

     Section 13. Termination of Coverage. (1) To terminate coverage in a QHP, an enrollee, including an enrollee who has obtained other minimum essential coverage, shall submit a request:

     (a) Via the KHBE Web site at www.kynect.ky.gov;

     (b) By telephone by contacting the KHBE contact center at 1-800-459-6328;

     (c) To the QHP issuer;

     (d) By mail; or

     (e) In person.

     (2) At the time of QHP selection, an enrollee in a QHP shall remain in a QHP if the enrollee:

     (a) Has been identified as eligible for other minimum essential coverage through the data matching described in 45 C.F.R. 155.330(d); and

     (b) Does not request termination in accordance with subsection (1) of this section.

     (3) The last day of coverage of an enrollee who terminates coverage in accordance with subsection (1) of this section shall be:

     (a) The termination date requested by the enrollee if the enrollee provides reasonable notice in accordance with subsection (7) of this section;

     (b) Fourteen (14) days after the termination is requested by the enrollee, if the enrollee does not provide reasonable notice in accordance with subsection (7) of this section;

     (c) A date determined by the issuer of an enrollee’s QHP if the issuer is able to terminate coverage in fewer than fourteen (14) days and the enrollee requests an earlier termination effective date; or

     (d) If the enrollee is newly eligible for Medicaid or KCHIP, the day before coverage in Medicaid or KCHIP begins.

     (4) An enrollee’s health coverage shall be terminated by an issuer if:

     (a) The enrollee is no longer eligible for coverage in a QHP through the KHBE;

     (b)1. The enrollee has failed to pay a premium; and

     2.a. A three (3) month grace period required for an individual receiving an APTC has been exhausted as described in 45 C.F.R. 156.270(g); or

     b. A thirty (30) day grace period required by KRS 304.17A-243 for an individual not receiving an APTC has been exhausted;

     (c) The enrollee’s coverage is rescinded in accordance with 45 C.F.R. 147.128 or KRS 304.14-110;

     (d) The enrollee is enrolled in a QHP that:

     1. Has been decertified pursuant to 900 KAR 10:010; or

     2. Has withdrawn from participation in the KHBE; or

     (e) The enrollee changes from one (1) QHP to another during an open enrollment period or special enrollment period in accordance with Section 6 or 7 of this administrative regulation.

     (5) The last day of coverage of an enrollee shall be:

     (a) If terminated in accordance with subsection (4)(a) of this section, the last day of the month following the month in which the notice described in subsection (7) of this section is sent by KHBE, unless the enrollee requests an earlier termination date in accordance with subsection (3) of this section;

     (b) If terminated in accordance with subsection (4)(b)2.a. of this section, the last day of the first month of the three (3) month grace period; or

     (c) If terminated in accordance with subsection (4)(b)2.b. of this section, in accordance with KRS 304.17A-245.

     (6) For an enrollee who is terminated in accordance with subsection (4)(e) of this section, the last day of coverage in an enrollee’s prior QHP shall be the day before the effective date of coverage in the enrollee’s new QHP.

     (7) Reasonable notice shall be fourteen (14) calendar days from the requested date of termination of coverage.

 

     Section 14. Authorized Representative. (1) An individual or employee may designate an individual or organization as an authorized representative:

     (a) 1. At the time of application; or

     2. At another time chosen by the individual or employee;

     (b) Through a method described in 45 C.F.R. 155.405(c)(2);

     (c) In writing with a signature or other legally binding format; and

     (d) Through a method described in Section 2(5) of this administrative regulation.

     (2) An authorized representative shall comply with state and federal laws regarding:

     (a) Conflict of interest; and

     (b) Confidentiality of information.

     (3) An applicant may authorize a representative to:

     (a) Sign an application on behalf of the applicant;

     (b) Submit an update or respond to a redetermination of eligibility for the applicant in accordance with Section 8 or 9 of this administrative regulation;

     (c) Receive a copy of a notice or communication from the KHBE;

     (d) Make an appeal request on behalf of an appellant; or

     (e) Act on behalf of the individual or employee in a matter with the KHBE.

     (4) The designation of an authorized representative shall be valid until:

     (a) An applicant or employee:

     1. Changes the authorization; or

     2. Notifies the KHBE and the authorized representative, through a method described in 45 C.F.R. 155.405(c), that the authorized representative is no longer authorized to act on behalf of the individual or employee; or

     (b) The authorized representative informs the KHBE and the individual or employee that the authorized representative is no longer acting as the authorized representative.

 

     Section 15. Appeals. (1) An applicant, a qualified individual, or an enrollee shall have the right to appeal an adverse determination.

     (2) An applicant shall have the right to appeal an exemption of the shared responsibility payment.

     (3) An applicant, qualified individual, or enrollee shall have the right to appeal an eligibility determination for Medicaid or KCHIP in accordance with 907 KAR 1:560.

     (4) An employer shall have the right to appeal a determination of an employee’s eligibility for APTC or CSR.

 

     Section 16. Incorporation by Reference. (1) The following material is incorporated by reference:

     (a) "Kentucky QHP/APTC Eligibility Verification Plan", June 2013;

     (b) "Guidance for Issuers on Special Enrollment Periods for Complex Cases in the Federally-facilitated Marketplace after the Initial Open Enrollment Period and Special Enrollment Period", March 26, 2014;

     (c) "Guidance for Issuers on People "In Line" for the Federally-facilitated Marketplace at the end of the Initial Open Enrollment Period", March 26, 2014; and

     (d) "Special Enrollment Periods and Hardship Exemptions for Persons Meeting Certain Criteria", May 2, 2014.

     (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office of the Kentucky Health Benefit Exchange, 12 Mill Creek Park, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m., or from its Web site at www.healthbenefitexchange.ky.gov. (40 Ky.R. 909; Am. 1283; eff. 1-3-2014; 41 Ky.R. 1206; 1560; eff. 2-5-2015.)

Notation

     RELATES TO: KRS 194A.050(1), 42 U.S.C. 18031, 45 C.F.R. Parts 155, 156

     STATUTORY AUTHORITY: KRS 194A.050(1)

     NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Kentucky Office of Health Benefit and Health Information Exchange, has responsibility to administer the state-based American 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 or to qualify for the receipt of federal funds. This administrative regulation establishes the policies and procedures relating to eligibility and enrollment in a qualified health plan in the individual market 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.