806 KAR 17:470. Data reporting to an

employer-organized association health benefit plan.

 

      RELATES TO: KRS 304.2-110(1),

304.17A-005, 304.17A-700(7), 304.17A-846(1), 45 C.F.R. 160, 45 C.F.R. 164

      STATUTORY AUTHORITY: KRS 304.2-110(1),

304.17A-846

      NECESSITY, FUNCTION, AND CONFORMITY: KRS

304.2-110(1) authorizes the executive director to promulgate reasonable

administrative regulations necessary for, or as an aid to, the effectuation of

any provision of the Kentucky Insurance Code as defined in KRS 304.1-010. KRS

304.17A-846 requires the office to promulgate an administrative regulation to

implement its provisions and define the extent that health benefit plan

information shall be provided to an employer-organized association. This

administrative regulation establishes requirements for the provision of health

benefit plan information to an employer-organized association by an insurer

offering a health benefit plan.

 

      Section 1. Definitions. (1)

"Aggregate claims experience" means the total dollar amount paid to

health care providers of medical and pharmacy services for persons covered

under an employer-organized association health benefit plan.

      (2) "Complete request" means a

written request for employer-organized association health benefit plan

information, including:

      (a) A certification by a designated

representative of the employer-organized association stating the:

      1. Employer-organized association health

benefit plan has

       adopted safeguards and standards for the

treatment of health information pursuant to 45 C.F.R. 164.504(f); and

      2. Information requested is the minimum

amount necessary to accomplish the intended purpose of the use or disclosure

pursuant to 45 C.F.R. 164.502(b) and 164.514(d); and

      (b) Specific and sufficient details

relating to the requested health benefit plan information.

      (3) "Electronically" is defined

in KRS 304.17A-700(7).

      (4) "Employer-organized

association" is defined by KRS 304.17A-005(12).

      (5) "Employer-organized association

health benefit plan" means a health benefit plan issued to an

employer-organized association or trust established by one (1) or more

employer-organized associations.

      (6) "Executive director" means

the Executive Director of the Office of Insurance.

      (7) "Health benefit plan" is

defined in KRS 304.17A-005(22).

      (8) "HIPAA" means Health

Insurance Portability and Accountability Act of 1996, Pub.L. 104-191.

      (9) "Office" means the Office

of Insurance.

 

      Section 2. Requirements for Provision of

Information. (1) Within five (5) business days of receipt of a written request

for information relating to an employer-organized association health benefit

plan, an insurer shall in writing:

      (a) Acknowledge receipt of the request;

and

      (b) If the request fails to be a complete

request, identify the items necessary to constitute a complete request in the

acknowledgment of receipt letter.

      (2) Pursuant to KRS 304.17A-846(1), an

insurer shall provide an employer-organized association with its health benefit

plan information, as requested:

      (a) Including:

      1. Total aggregate claims experience;

      2. Total premiums paid by the

employer-organized association;

      3. Total number of persons covered under

the employer-organized association health benefit plan, by coverage tier, as follows:

      a. Family;

      b. Individual;

      c. Individual and spouse;

      d. Individual and domestic partner; and

      e. Parent plus; and

      4. Information required under KRS

304.17A-846(1)(d); and

      (b) Within thirty (30) calendar days of

receipt of a complete request.

      (3) An insurer may:

      (a) Except if an employer-organized

association specifies the method for the delivery of its health benefit plan

information, provide the requested information in one (1) of the following

formats:

      1. Electronically, pursuant to the

requirements for electronic transmission of information as established in 45

C.F.R. 160 and 164; or

      2. Hard copy; and

      (b) Request an extension of the timeframe

for providing an employer-organized association with its health benefit plan

information in whole or in part, if the insurer:

      1. Provides evidence to the

employer-organized association that a disruption in electricity and

communication connections beyond its control has occurred; or

      2. Establishes that an unusual

circumstance exists that precludes the provision of health benefit plan

information electronically or in hard copy format; and

      3. Deny a complete request if:

      a. A determination is made by the United

States Department of Health and Human Services Office for Civil Rights that

provision of health benefit plan information as requested by the employer-organized

association is prohibited under HIPAA; and

      b. A copy of the determination, as

established under clause a of this subparagraph, is provided to the

employer-organized association which submits a complete request.

 

      Section 3. Preemption. This

administrative regulation shall not:

      (1) Preempt or supersede an existing Kentucky

law relating to a medical record, health, or insurance information privacy; or

      (2) Infringe upon the jurisdiction of the

United States Department of Health and Human Services Office for Civil Rights

in its:

      (a) Enforcement of 45 C.F.R. 160 and 164;

and

      (b) Responding to a complaint relating to

privacy of health information. (32 Ky.R. 573; 915; eff. 2-3-2006.)