History: L. 1951, ch. 300, § 1; April 1.
(a) Reasonable rules governing the equitable distribution of risks by direct insurance, reinsurance or otherwise and their assignment to insurers, including provisions requiring, at the request of the applicant, an immediate assumption of the risk by an insurer or insurers upon completion of an application, payment of the specified premium and deposit the application and the premium in the United States mail, postage prepaid and addressed to the plan's office;
(b) rates and rate modifications applicable to such risks which shall be reasonable, adequate and not unfairly discriminatory;
(c) the limits of liability which the insurer shall be required to assume;
(d) a method whereby applicants for insurance, insureds and insurers may have a hearing on grievances and the right of appeal to the commissioner;
(e) for every such plan or plans, there shall be a governing board to be appointed by the commissioner of insurance which shall meet at least annually to review and prescribe operating rules, and which shall consist of the following members:
(1) Seven members who shall be appointed as follows: Three of such members shall be representatives of foreign insurance companies, two members shall be representatives of domestic insurance companies and two members shall be licensed independent insurance agents. Such members shall be appointed for a term of three years, except that the initial appointment shall include two members appointed for a two-year term and two members appointed for a one-year term as designated by the commissioner; and
(2) Two members representative of the general public interest with such members to be appointed for a term of two years.
The commissioner shall review the plan as soon as reasonably possible after filing in order to determine whether it meets the requirements set forth in (a), (b), (c) and (d) above. As soon as reasonably possible after the plan has been filed the commissioner shall in writing approve or disapprove the same. Any plan shall be deemed approved unless disapproved within 45 days. Subsequent to the waiting period the commissioner may disapprove any plan on the ground that it does not meet the requirements set forth in (a), (b), (c) and (d) above, but only after a hearing held upon not less than 10 days' written notice to every insurer and rating organization affected specifying the matter to be considered at such hearing, and only by an order specifying in what respect the commissioner finds that such plan fails to meet such requirements, and stating when within a reasonable period thereafter such plan shall be deemed no longer effective. Such order shall not affect any assignment made or policy issued or made prior to the expiration of the period set forth in such order. Amendments to such plan or plans shall be prepared, and filed and reviewed in the same manner as herein provided with respect to the original plan or plans.
If no plan meeting the standards set forth in (a), (b), (c) and (d) is submitted to the commissioner within the period stated in any order disapproving an existing plan the commissioner shall, if necessary to carry out the purpose of this section after hearing, prepare and promulgate a plan meeting such requirements. If, after a hearing conducted in accordance with the provisions of the Kansas administrative procedure act, the commissioner finds that any activity or practice of any insurer or rating organization in connection with the operation of such plan or plans is unfair or unreasonable or otherwise inconsistent with the provisions of this subsection the commissioner may issue a written order specifying in what respects such activity or practice is unfair or unreasonable or otherwise inconsistent with the provisions of this subsection and requiring discontinuance of such activity or practice.
History: L. 1951, ch. 300, § 2; L. 1969, ch. 238, § 7; L. 1978, ch. 182, § 1; L. 1988, ch. 356, § 103; July 1, 1989.
History: L. 1951, ch. 300, § 3; April 1.
History: L. 1951, ch. 300, § 4; April 1.
History: L. 1957, ch. 288, § 1; April 16.
History: L. 1957, ch. 288, § 2; L. 1988, ch. 356, § 104; July 1, 1989.
History: L. 1957, ch. 288, § 3; April 16.
History: L. 1961, ch. 239, § 1; June 30.
(a) Reasonable rules governing the equitable distribution of risks by direct insurance, reinsurance or otherwise and their assignment to insurers;
(b) rates and rate modifications applicable to such risks which shall be reasonable, adequate and not unfairly discriminatory;
(c) a method whereby applicants for insurance, insured and insurers may have a hearing on grievances and the right of appeal to the commissioner;
(d) for every such plan or plans, there shall be a governing board to be appointed by the commissioner of insurance which shall meet at least annually to review and prescribe operating rules, and which shall consist of the following members:
(1) Seven members who shall be appointed as follows: Three of such members shall be representatives of foreign insurance companies, two members shall be representatives of domestic insurance companies and two members shall be licensed independent insurance agents. Such members shall be appointed for a term of three years, except that the initial appointment shall include two members appointed for a two-year term and two members appointed for a one-year term, as designated by the commissioner; and
(2) Two members representative of the general public interest with such members to be appointed for a term of two years.
The commissioner shall review the plan as soon as reasonably possible after filing in order to determine whether it meets the requirements set forth in subsections (a) and (c) above. As soon as reasonably possible after the plan has been filed the commissioner shall in writing approve or disapprove the same, except that any plan shall be deemed approved unless disapproved within 45 days. Subsequent to the waiting period the commissioner may disapprove any plan on the ground that it does not meet the requirements set forth in subsections (a), (b) and (c) above, but only after a hearing held upon not less than 10 days' written notice to every insurer and rating organization affected specifying the matter to be considered at such hearing, and only by an order specifying in what respect the commissioner finds that such plan fails to meet such requirements and stating when within a reasonable period thereafter such plan shall be deemed no longer effective. Such order shall not affect any assignment made or policy issued or made prior to the expiration of the period set forth in such order. Amendments to such plan or plans shall be prepared, and filed and reviewed in the same manner as herein provided with respect to the original plan or plans.
If no plan meeting the standards set forth in subsections (a), (b) and (c) is submitted to the commissioner within the period stated in any order, disapproving an existing plan the commissioner shall, if necessary to carry out the purpose of this section after hearing, prepare and promulgate a plan meeting such requirements. When such plan or plans or amendments thereto have been approved or promulgated, no insurer shall thereafter issue a policy of workers compensation or employer's liability insurance or undertake to transact such business in this state unless such insurer shall participate in such an approved or promulgated plan. If, after a hearing conducted in accordance with the provisions of the Kansas administrative procedure act, the commissioner finds that any activity or practice of any insurer or rating organization in connection with the operation of such plan or plans is unfair or unreasonable or otherwise inconsistent with the provisions of this section the commissioner may issue a written order specifying in what respects such activity or practice is unfair or unreasonable or otherwise inconsistent with the provisions of this section and requiring discontinuance of such activity or practice.
(e) The commissioner shall approve rates and rate modifications for each plan that provides workers compensation insurance pursuant to this section which, over a period of time, but no later than January 1, 1997, will reduce the assessments levied by the plan to less than 10%. If the commissioner finds that the percentage of the total Kansas workers compensation premium volume written by the plan has not decreased below 20% of the total amount of such premium volume by December 31, 1998, the provisions of this subsection shall no longer apply and the commissioner may cause the governing board of the plan to file new rates and rate modifications pursuant to this section. Notwithstanding the foregoing provisions of this subsection, the commissioner shall not approve rates or rating plans which produce rates or premiums for risks with less than $2,250 annual premium that are higher than those which would be applied to such risks in the voluntary market, except that this provision shall not prohibit the application of surcharges, experience modifications or other rating variables based on the claims experience of individual risks.
History: L. 1961, ch. 239, § 2; L. 1969, ch. 238, § 8; L. 1988, ch. 356, § 105; L. 1993, ch. 286, § 23; July 1.
History: L. 1961, ch. 239, § 3; June 30.
(b) Such plan or plans shall provide:
(1) Reasonable rules governing the equitable distribution of risks, by direct insurance, reinsurance or otherwise, and their assignment to insurers;
(2) rates and rate modifications applicable to such risks which shall be reasonable, adequate and not unfairly discriminatory;
(3) the extent of liability which each insurer shall be required to assume; and
(4) a method whereby applicants for insurance, insureds, agents and insurers may have a hearing on grievances and the right of appeal of the commissioner.
For every such plan or plans, there shall be a governing board, to be appointed by the commissioner of insurance, which shall meet at least annually to review and prescribe operating rules, and which shall consist of the following members:
(A) Seven members who shall be appointed as follows: Three members shall be representatives of foreign insurance companies, two members shall be representatives of domestic insurance companies and two members shall be licensed independent insurance agents. Such members shall be appointed for a term of three years, except that the initial appointment shall include two members appointed for a two-year term and two members appointed for a one-year term, as designated by the commissioner; and
(B) Two members representative of the general public interest, with such members to be appointed for a term of two years.
(c) With regard to accident and sickness insurance, prior to the implementation of a plan under this section: (1) Every insurer shall report to the commissioner at such time as the commissioner may require, on a form prescribed by the commissioner, information concerning each instance of declination of insurance coverage, termination of insurance coverage and offering to insure at higher than standard rates, with respect to the type of insurance proposed to be provided under this section; (2) the commissioner shall report to the governor and to the legislature, no later than the commencement of the 1988 regular session of the Kansas legislature, data obtained under the provisions of this section along with a proposed plan, including an analysis of the cost impact thereof, developed in accordance with this section; (3) the legislature shall have an opportunity to review the data and comment on whether there is a need for implementation of the plan; and (4) approval by the legislature must be obtained.
History: L. 1969, ch. 238, § 1; L. 1986, ch. 178, § 1; July 1.
History: L. 1969, ch. 238, § 2; July 1.
History: L. 1969, ch. 238, § 3; L. 1988, ch. 356, § 106; July 1, 1989.
History: L. 1969, ch. 238, § 4; July 1.
History: L. 1969, ch. 238, § 5; L. 1988, ch. 356, § 107; July 1, 1989.
History: L. 1969, ch. 238, § 6; July 1.
History: L. 1992, ch. 209, § 1; July 1.
(a) "Administering carrier" means the insurer or third-party administrator designated in K.S.A. 40-2120, and amendments thereto.
(b) "Association" means the Kansas health insurance association established in K.S.A. 40-2119, and amendments thereto.
(c) "Board" means the board of directors of the association.
(d) "Church plan" means a plan as defined under section 3(33) of the Employee Retirement Income Security Act of 1974.
(e) "Commissioner" means the commissioner of insurance.
(f) "Creditable coverage" means with respect to an individual, coverage of the individual under any of the following:
(1) A group health plan;
(2) health insurance coverage;
(3) part A or part B of Title XVIII of the Social Security Act;
(4) title XIX of the Social Security Act, other than coverage consisting solely of benefit under Section 1928;
(5) chapter 55 of Title 10, United States Code;
(6) a medical care program of the Indian Health Service or of a tribal organization;
(7) a state health benefit risk pool;
(8) a health plan offered under Chapter 89 of Title 5, United States Code;
(9) a public health plan as defined under regulations promulgated by the secretary of health and human services; and
(10) a health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(d)).
(g) "Dependent" means a resident spouse or resident unmarried child under the age of 19 years, a child who is a student under the age of 23 years and who is financially dependent upon the parent, or a child of any age who is disabled and dependent upon the parent.
(h) "Excess loss" means the total dollar amount by which claims expense incurred for any issuer of a medicare supplement policy or certificate delivered or issued for delivery to persons in this state eligible for medicare by reason of disability and who are under age 65 exceeds 65% of the premium earned by such issuer during a calendar year.
(i) "Federally defined eligible individual" means an individual:
(1) For whom, as of the date the individual seeks coverage under this section, the aggregate of the periods of creditable coverage is 18 or more months and whose most recent prior coverage was under a group health plan, government plan or church plan;
(2) who is not eligible for coverage under a group health plan, Part A or B of Title XVII of the Social Security Act, or a state plan under Title XIX of the Social Security Act, or any successor program, and who does not have any other health insurance coverage;
(3) with respect to whom the most recent coverage was not terminated for factors relating to nonpayment of premiums or fraud; and
(4) who had been offered the option of continuation coverage under COBRA or under a similar program, who elected such continuation coverage, and who has exhausted such continuation coverage.
(j) "Federally defined eligible individuals for FTAA" means an individual who is:
(1) Legally domiciled in this state; and
(2) eligible for the credit for health insurance costs under section 35 of the internal revenue code of 1986.
(k) "FTAA" means federal trade adjustment assistance under the federal trade adjustment assistance reform act of 2002, public law 107-210.
(l) "Governmental plan" means a plan as defined under section 3(32) of the Employee Retirement Income Security Act of 1974 and any plan maintained for its employees by the government of the United States or by any agency or instrumentality of such government.
(m) "Group health plan" means an employee benefit plan as defined by section 3(1) of the Employee Retirement Income Security Act of 1974 to the extent that the plan provides any hospital, surgical or medical expense benefits to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement or otherwise.
(n) "Health insurance" means any hospital or medical expense policy, health, hospital or medical service corporation contract, and a plan provided by a municipal group-funded pool, or a health maintenance organization contract offered by an employer or any certificate issued under any such policies, contracts or plans. "Health insurance" does not include policies or certificates covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, specified disease, vision care, coverage issued as a supplement to liability insurance, insurance arising out of a workers compensation or similar law, automobile medical-payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(o) "Health maintenance organization" means any organization granted a certificate of authority under the provisions of the health maintenance organization act.
(p) "Insurance arrangement" means any plan, program, contract or any other arrangement under which one or more employers, unions or other organizations provide to their employees or members, either directly or indirectly through a group-funded pool, trust or third-party administrator, health care services or benefits other than through an insurer.
(q) "Insurer" means any insurance company, fraternal benefit society, health maintenance organization and nonprofit hospital and medical service corporation authorized to transact health insurance business in this state.
(r) "Medicaid" means the medical assistance program operated by the state under title XIX of the federal social security act.
(s) "Medicare" means coverage under both parts A and B of title XVIII of the federal social security act, 42 USC 1395.
(t) "Medicare supplement policy" means a group or individual policy of accident and sickness insurance or a subscriber contract of hospitals and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under section 1876 of the federal social security act (42 USC 1395 et seq.) or an issued policy under a demonstration project specified in 42 USC 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under medicare for the hospital, medical or surgical expenses of persons eligible for medicare.
(u) "Member" means all insurers and insurance arrangements participating in the association.
(v) "Plan" means the Kansas uninsurable health insurance plan created pursuant to this act.
(w) "Plan of operation" means the plan to create and operate the Kansas uninsurable health insurance plan, including articles, bylaws and operating rules, adopted by the board pursuant to K.S.A. 40-2119, and amendments thereto.
History: L. 1992, ch. 209, § 2; L. 1997, ch. 190, § 7; L. 1999, ch. 106, § 1; L. 2004, ch. 159, § 8; May 27.
(b) (1) The board of directors of the association shall be selected by members of the association subject to the approval of the commissioner. To select the initial board of directors, and to initially organize the association, the commissioner shall give notice to all members in this state of the time and place of the organizational meeting. In determining voting rights at the organizational meeting, each member shall be entitled to one vote in person or by proxy. If the board of directors is not selected within 60 days after the organizational meeting, the commissioner shall appoint the initial board. In approving or selecting members of the board, the commissioner shall consider, among other things, whether all members are fairly represented. Members of the board may be reimbursed from the moneys of the plan for expenses incurred by them as members of the board of directors but shall not otherwise be compensated by the plan for their services.
(2) The board shall submit to the commissioner a plan of operation for the association and any amendments thereto necessary or suitable to assure the fair, reasonable and equitable administration of the plan. The plan of operation shall become effective upon approval in writing by the commissioner consistent with the date on which the coverage under this act must be made available. The commissioner shall, after notice and hearing, approve the plan of operation if it is determined to be suitable to assure the fair, reasonable and equitable administration of the plan and provides for the sharing of association losses on an equitable proportionate basis among the members of the association. If the board fails to submit a suitable plan of operation within 180 days after its appointment, or at any time thereafter fails to submit suitable amendments to the plan of operation, the commissioner shall, after notice and hearing, adopt and promulgate such reasonable rules and regulations as are necessary or advisable to effectuate the provisions of this section. Such rules and regulations shall continue in force until modified by the commissioner or superseded by a plan of operation submitted by the board and approved by the commissioner. The plan of operation shall, in addition to requirements enumerated elsewhere in this act:
(A) Establish procedures for the handling and accounting of assets and moneys of the plan;
(B) select an administering carrier in accordance with K.S.A. 40-2120, and amendments thereto;
(C) establish procedures for the collection of assessments from all members to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board pursuant to K.S.A. 40-2121, and amendments thereto. Assessments shall be due and payable within 30 days of receipt of the assessment notice;
(D) establish appropriate cost control measures, including but not limited to, preadmission review, case management, utilization review and exclusions and limitations with respect to treatment and services under the plan; and
(E) develop and implement a program to publicize the existence of the plan, the eligibility requirements and procedures for enrollment and to maintain public awareness of the plan.
(F) Establish benefit levels, lifetime maximum benefits, and other coverage and eligibility parameters, and establish such other requirements and procedures as are necessary to assure the availability of a benefit program or programs conforming with the requirements of a qualified high risk pool as set forth in section 111 of Public Law 104-191 and amendments thereto.
(c) The association shall have the general powers and authority enumerated by this subsection in accordance with the plan of operation approved by the commissioner under subsection (b). The association shall have the general powers and authority granted under the laws of this state to insurers licensed to transact the kind of health service or insurance included under K.S.A. 40-2123, and amendments thereto, and in addition thereto, the specific authority and duty to:
(1) Enter into contracts as are necessary or proper to carry out the provisions and purposes of this act, including the authority, with the approval of the commissioner, to enter into contracts with similar plans of other states for the joint performance of common administrative functions, or with persons or other organizations for the performance of administrative functions;
(2) sue or be sued, including taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against participating members;
(3) take such legal action as necessary to avoid the payment of improper claims against the association or the coverage provided by or through the plan;
(4) establish appropriate rates, rate schedules, rate adjustments, expense allowances, agents' referral fees, claim reserve formulas and any other actuarial function appropriate to the operation of the plan. During the first two years of operation of the plan, rates shall be established in an amount that is estimated by the board to cover all claims that may be made against the plan and the expenses of operating the plan. In following years, rates for coverage shall be reasonable in terms of the benefits provided, the risk experience and expenses of providing the coverage, except that such rates shall not exceed 150% of the average premium rate charged for similar coverage in the private market. Rates and rate schedules may be adjusted for appropriate risk factors such as age, sex and geographic location in claims costs and shall take into consideration appropriate risk factors in accordance with established actuarial and underwriting practices, however particular health conditions or illnesses shall not constitute appropriate risk factors;
(5) assess members of the association in accordance with the provisions of K.S.A. 40-2121, and amendments thereto;
(6) design the policies of insurance to be offered by the plan which shall cover at least the expenses enumerated in subsection (b) of K.S.A. 40-2123, and amendments thereto, but with such limitations and optional benefit levels as the plan prescribes;
(7) issue policies of insurance in accordance with the requirements of this act; and
(8) appoint from among members appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the plan, policy and other contract design, and any other function within the authority of the association.
(d) The association shall administer a reinsurance program for medicare supplement policies issued to Kansas residents who are eligible for medicare by reason of disability. All medicare supplement insurers issuing or renewing medicare supplement policies in this state shall be participants in such reinsurance program. (1) On or before May 1, 2000, and each year thereafter, each issuer of a medicare supplement policy in the state shall provide to the association a calendar year accounting of the medicare supplement policies delivered or issued for delivery in the state and covering persons eligible for medicare by reason of disability who are under age 65. (2) The accounting for medicare supplement policies covering persons eligible by reason of disability and under age 65 shall include the total number of such persons covered, the total premium earned on such persons, and the total claims expense incurred with respect to such persons during such year as paid through March 31, without estimates for incurred but not reported claims. (3) The association shall use such reports to develop the assessment required under subsection (d) of K.S.A. 40-2121, and amendments thereto.
History: L. 1992, ch. 209, § 3; L. 1996, ch. 98, § 1; L. 1997, ch. 190, § 8; L. 1999, ch. 106, § 2; July 1.
(1) The bidder's proven ability to handle individual accident and health insurance;
(2) the efficiency of the bidder's claim paying procedure;
(3) an estimate of total charges for administering the plan; and
(4) the bidder's ability to administer the plan in a cost efficient manner.
(b) The administering carrier so selected shall serve for a period of three years subject to removal for cause. At least one year prior to the expiration of each three-year period of service, the board shall invite all interested parties, including the current administering carrier, to submit bids to serve as the administering carrier for the succeeding three-year period. Selection of the administering carrier for the succeeding period shall be made at least six months prior to the end of the current three-year period. The administering carrier shall be paid as provided in the plan of operation.
(c) The administering carrier shall perform all administrative, eligibility and administrative claims payment functions relating to the plan, including:
(1) Establishing a billing procedure for collection of premiums from insured persons. Billings shall be made on a periodic basis as determined by the board, which shall not be more frequent than a monthly billing;
(2) performing all necessary functions to assure timely payment of benefits to covered persons under the plan including making available information relating to the proper manner of submitting a claim for benefits to the plan, distributing forms upon which submission shall be made and evaluating the eligibility of each claim for payment under the plan;
(3) accepting payments of premiums from insured persons and remitting such payments to the state treasurer in accordance with the provisions of K.S.A. 75-4215, and amendments thereto. Upon receipt of each such remittance, the state treasurer shall deposit the entire amount in the state treasury to the credit of the uninsurable health insurance plan fund established in K.S.A. 40-2126, and amendments thereto;
(4) submitting regular reports to the board regarding the operation of the plan. The frequency, content and form of the reports shall be as determined by the board;
(5) determining net written and earned premiums, the expense of administration, and the paid and incurred losses for each year and reporting such information to the board and the commissioner in a form and manner prescribed by the commissioner.
History: L. 1992, ch. 209, § 4; L. 2001, ch. 5, § 116; July 1.
(b) In addition to any assessment authorized by subsection (a), the board may assess the members of the association for any initial costs associated with developing and implementing the plan to the extent such costs exceed the funds transferred to the uninsurable health insurance plan fund pursuant to K.S.A. 40-2125 and amendments thereto. Such assessment shall be allocated among the members of the association in the manner prescribed by subsection (a) of this section or any other equitable formula established by the board. Assessments under this subsection shall not be subject to the credit against premium tax under subsection (c).
(c) For taxable years commencing after December 31, 1995, and prior to January 1, 1998, 80% of any assessment made against a member of the association pursuant to subsection (a) of this section may be claimed by such member as a credit against such member's premium or privilege tax liability imposed by K.S.A. 12-2624, 40-252 or 40-3213 and amendments thereto, for the taxable year in which such assessment is paid. For the tax year commencing after December 31, 1997, 70% of any assessment made against a member of the association pursuant to subsection (a) of this section may be claimed by such member as a credit against such member's premium tax liability imposed by K.S.A. 12-2624, 40-252 or 40-3213 and amendments thereto, for the taxable year in which such assessment is paid.
For the tax year commencing after December 31, 1998, 65% of any assessment made against a member of the association pursuant to subsection (a) of this section may be claimed by such member as a credit against such member's premium tax liability imposed by K.S.A. 12-2624, 40-252 or 40-3213 and amendments thereto, for the taxable year in which such assessment is paid.
For the tax year commencing after December 31, 1999, 60% of any assessment made against a member of the association pursuant to subsection (a) of this section may be claimed by such member as a credit against such member's premium tax liability imposed by K.S.A. 12-2624, 40-252 or 40-3213 and amendments thereto, for the taxable year in which such assessment is paid.
(d) In addition to the assessments otherwise authorized herein, the board shall assess all issuers of medicare supplement policies covering persons within this state to the extent necessary to assure that the excess losses, if any, are distributed among such issuers of medicare supplement policies in a ratio equal to the percentage market share in Kansas of each such issuer for medicare supplement policies covering persons eligible for medicare by reason of age. The association shall also assess to such issuers of medicare supplement policies the costs the association incurs in operating the reinsurance program, making assessments, and collecting and distributing moneys, which shall be assessed pro rata to such issuers based on the market share of such issuers of medicare supplement policies covering persons eligible for medicare by reason of age. Such assessment shall occur not later than July 1 of each year, based on such excess losses and such market shares for the immediately preceding calendar year. Issuers of medicare supplement policies shall remit the amount so assessed to the association within the time frames established by the board for payment of assessment otherwise authorized herein. The association shall pay to any issuer of medicare supplement policies entitled thereto such amount as is necessary to result in the equalization among all issuers of medicare supplement policies in Kansas of excess losses in a proportion equivalent to the percentage market share in Kansas of each issuer of medicare supplement policies covering persons eligible for medicare by reason of age. The amount of such assessments received by an insurer shall not be accounted for as premium income nor shall such amounts be subject to premium tax. The amount of such assessments shall not be available for use in premium tax credits provided for under subsection (c) of K.S.A. 40-2122, and amendments thereto. The association shall have the ability to enforce assessments through its board.
History: L. 1992, ch. 209, § 5; L. 1996, ch. 98, § 2; L. 1997, ch. 190, § 9; L. 1999, ch. 106, § 3; L. 2000, ch. 34, § 1; July 1.
(1) Any person who has been a resident of this state for at least six months;
(2) any person who is a legal domiciliary of this state who previously was covered under the high risk pool of another state, provided they apply for coverage under the plan within 63 days of losing such other coverage for reasons other than fraud or nonpayment of premiums;
(3) any federally defined eligible individual who is a legal domiciliary of this state; or
(4) any federally defined eligible individual for FTAA.
(b) Those individuals who are eligible for plan coverage under subsection (a) must provide evidence satisfactory to the administering carrier that such person meets one of the following criteria:
(1) Such person has had health insurance coverage involuntarily terminated for any reason other than nonpayment of premium;
(2) such person has applied for health insurance and been rejected by two carriers because of health conditions;
(3) such person has applied for health insurance and has been quoted a premium rate which is in excess of the plan rate;
(4) such person has been accepted for health insurance subject to a permanent exclusion of a preexisting disease or medical condition;
(5) such person is a federally defined eligible individual; or
(6) such person is a federally defined eligible individual for FTAA.
(c) Each resident dependent of a person who is eligible for plan coverage shall also be eligible for plan coverage.
(d) The following persons shall not be eligible for coverage under the plan:
(1) Any person who is eligible for medicare or is eligible for medicaid benefits;
(2) any person who has had coverage under the plan terminated less than 12 months prior to the date of the current application, except that this provision shall not apply with respect to an applicant who is a federally defined eligible individual;
(3) any person who has received accumulated benefits from the plan equal to or in excess of the lifetime maximum benefits under the plan prescribed by K.S.A. 40-2124 and amendments thereto;
(4) any person having access to accident and health insurance through an employer-sponsored group or self-insured plan, including coverage under the consolidated omnibus budget reconciliation act (COBRA), except that the requirement for exhaustion of any available COBRA or state continuation is waived whenever such person:
(A) Is eligible for the credit for health care costs under section 35 of the internal revenue code of 1986; and
(B) has three months of prior creditable coverage as described in subsection (c) of K.S.A. 40-2124, and amendments thereto; or
(5) any person who is eligible for any other public or private program that provides or indemnifies for health services.
(e) Any person who ceases to meet the eligibility requirements of this section may be terminated at the end of a policy period.
(f) All plan members, insurers and insurance arrangements shall notify in writing persons denied health insurance coverage, for any reason, of the availability of coverage through the Kansas health insurance association.
History: L. 1992, ch. 209, § 6; L. 1995, ch. 129, § 1; L. 1997, ch. 190, § 10; L. 1998, ch. 174, § 4; L. 1999, ch. 30, § 1; L. 2004, ch. 159, § 9; May 27.
(b) Except for those expenses set forth in subsection (c) of this section, expenses covered under the plan shall include expenses for:
(1) Services of persons licensed to practice medicine and surgery which are medically necessary for the diagnosis or treatment of injuries, illnesses or conditions;
(2) services of advanced registered nurse practitioners who hold a certificate of qualification from the board of nursing to practice in an expanded role or physicians assistants acting under the direction of a responsible physician when such services are provided at the direction of a person licensed to practice medicine and surgery and meet the requirements of paragraph (b)(1) above;
(3) services of licensed dentists when such procedures would otherwise be performed by persons licensed to practice medicine and surgery;
(4) emergency care, surgery and treatment of acute episodes of illness or disease as defined in the plan and provided in a general hospital or ambulatory surgical center as such terms are defined in K.S.A. 65-425, and amendments thereto;
(5) medically necessary diagnostic laboratory and x-ray services;
(6) drugs and controlled substances prescribed by a practitioner, as defined in K.S.A. 65-1626 and amendments thereto, or drugs and controlled substances prescribed by a mid-level practitioner as defined in K.S.A. 65-1626 and amendments thereto. Coverage for outpatient prescriptions shall be subject to a mandatory 50% coinsurance provision, and coverage for prescriptions administered to inpatients shall be subject to a coinsurance provision as established in the plan; and
(7) subject to the approval of the commissioner, the board shall also review and recommend the inclusion of coverage for mental health services and such other primary and preventive health care services as the board determines would not materially impair affordability of the plan.
(c) Expenses not covered under the plan shall include expenses for:
(1) Illness or injury due to an act of war;
(2) services rendered prior to the effective date of coverage under this plan for the person on whose behalf the expense is incurred;
(3) services for which no charge would be made in the absence of insurance or for which the insured bears no legal obligation to pay;
(4) (A) services or charges incurred by the insured which are otherwise covered by:
(i) Medicare or state law or programs;
(ii) medical services provided for members of the United States armed forces and their dependents or for employees of such armed forces;
(iii) military service-connected disability benefits;
(iv) other benefit or entitlement programs provided for by the laws of the United States (except title XIX of the social security act of 1965);
(v) workers compensation or similar programs addressing injuries, diseases, or conditions incurred in the course of employment covered by such programs;
(vi) benefits payable without regard to fault pursuant to any motor vehicle or other liability insurance policy or equivalent self-insurance.
(B) This exclusion shall not apply to services or charges which exceed the benefits payable under the applicable programs listed above and which are otherwise eligible for payment under this section.
(5) Services the provision of which is not within the scope of the license or certificate of the institution or individual rendering such service;
(6) that part of any charge for services or articles rendered or prescribed which exceeds the rate established by K.S.A. 40-2131 and amendments thereto for such services;
(7) services or articles not medically necessary;
(8) care which is primarily custodial or domiciliary in nature;
(9) cosmetic surgery unless provided as the result of an injury or medically necessary surgical procedure;
(10) eye surgery if corrective lenses would alleviate the problem;
(11) experimental services or supplies not generally recognized as the normal mode of treatment for the illness or injury involved;
(12) service of a blood donor and any fee for failure of the insured to replace the first three pints of blood provided in each calendar year; and
(13) personal supplies or services provided by a health care facility or any other nonmedical or nonprescribed supply or service.
(d) Except as expressly provided for in this act, no law requiring the coverage or the offer of coverage of a health care service or benefit shall apply to the plan.
(e) A plan may incorporate provisions that will direct covered persons to the most appropriate lowest cost health care provider available.
History: L. 1992, ch. 209, § 7; L. 1993, ch. 132, § 5; L. 1997, ch. 184, § 1; L. 1999, ch. 115, § 6; L. 2007, ch. 177, § 28; May 17.
(b) Coverage under the plan shall be subject to a maximum lifetime benefit of $1,000,000 per covered individual.
(c) On and after May 1, 1994, coverage under the plan shall exclude charges or expenses incurred during the first 90 days following the effective date of coverage as to any condition: (1) Which manifested itself during the six-month period immediately prior to the application for coverage in such manner as would cause an ordinarily prudent person to seek diagnosis, care or treatment; or (2) for which medical advice, care or treatment was recommended or received in the six-month period immediately prior to the application for coverage. In succeeding years of operation of the plan, coverage of preexisting conditions may be excluded as determined by the board, except that no such exclusion shall exceed 180 calendar days, and no exclusion shall be applied to a federally defined eligible individual provided that application for coverage is made not later than 63 days following the applicant's most recent prior creditable coverage. For any individual who is eligible for the credit for health insurance costs under section 35 of the internal revenue code of 1986, the preexisting conditions limitation will not apply whenever such individual has maintained creditable health insurance coverage for an aggregate period of three months, not counting any period prior to a 63 day break in coverage, as of the date on which such individual seeks to enroll in coverage provided by this act.
(d) (1) Benefits otherwise payable under plan coverage shall be reduced by all amounts paid or payable through any other health insurance, or insurance arrangement, and by all hospital and medical expense benefits paid or payable under any workers compensation coverage, automobile medical payment or liability insurance whether provided on the basis of fault or nonfault, and by any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program.
(2) The association shall have a cause of action against an eligible person for the recovery of the amount of benefits paid which are not covered expenses. Benefits due from the plan may be reduced or refused as a set-off against any amount recoverable under this section.
History: L. 1992, ch. 209, § 8; L. 1994, ch. 125, § 1; L. 1997, ch. 190, § 11; L. 2004, ch. 159, § 10; May 27.
History: L. 1992, ch. 209, § 9; July 1.
History: L. 1992, ch. 209, § 10; July 1.
(b) The financial status of the plan shall be subject to examination by the commissioner or the commissioner's designee. Such examination shall be conducted at least once every three years beginning January 1, 1995. The commissioner shall transmit a copy of the results of such examination to the legislature by February 1 of the year following the year in which the examination is conducted.
History: L. 1992, ch. 209, § 11; July 1.
History: L. 1992, ch. 209, § 12; July 1.
History: L. 1992, ch. 209, § 13; July 1.
History: L. 1992, ch. 209, § 14; July 1.
History: L. 1992, ch. 209, § 15; July 1.