Kansas Statutes 40-2124. Same; deductible and copayment provisions; maximum lifetime benefit; preexisting conditions exclusion; reduction of plan benefits for duplicate coverage; recovery of benefits paid for noncovered expenses
Terms Used In Kansas Statutes 40-2124
- Association: means the Kansas health insurance association established in Kan. See Kansas Statutes 40-2118
- Board: means the board of directors of the association. See Kansas Statutes 40-2118
- 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;
(10) a health benefit plan under section 5(e) of the peace corps act (22 U. See Kansas Statutes 40-2118
- 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 if offered the option of continuation coverage under COBRA or under a similar program, elected such continuation coverage, and has exhausted such continuation coverage. See Kansas Statutes 40-2118
- 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. See Kansas Statutes 40-2118
- 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. See Kansas Statutes 40-2118
- Plan: means the Kansas uninsurable health insurance plan created pursuant to this act. See Kansas Statutes 40-2118
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Kansas Statutes 77-201
(a) Coverage under the plan shall be subject to both deductible and coinsurance provisions set by the board. The plan shall offer to current participants and new enrollees no fewer than four choices of deductible and copayment options. Coverage shall contain a coinsurance provision for each service covered by the plan, and such copayment requirement shall not be subject to a stop-loss provision. Such coverage may provide for a percentage or dollar amount of coinsurance reduction at specific thresholds of copayment expenditures by the insured.
(b) Coverage under the plan shall be subject to a maximum lifetime benefit of $4,000,000 per covered individual.
(c) 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 either 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 or an individual under the age of 19 years who is eligible for enrollment in the plan under paragraph (3) of subsection (b) of Kan. Stat. Ann. § 40-2122, and amendments thereto. 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.