Plan types (indemnity, HMO, PPO, POS, HDHP with an HSA), cost-sharing terms, and the federal Affordable Care Act rules are covered in the national Medical Plans guide. Kentucky regulates health benefit plans under Subtitle 17A of KRS Chapter 304. That subtitle covers renewability, grace and cancellation, required benefits, and prompt payment. Group continuation and conversion are in the Kentucky group health guide. Individual policy provisions are in the Kentucky individual accident and health provisions guide.

Renewal, grace and cancellation

• Guaranteed renewability (KRS 304.17A-240). Health benefit plans renew at the insured's option. An insurer may cancel or nonrenew only for:
  • nonpayment
  • fraud or intentional misrepresentation of a material fact
  • abusive noncompliance
  • market withdrawal
  • the enrollee leaving the service area
  • loss of association membership
  • a group's failure to meet participation requirements
• Market withdrawal. If an insurer stops offering a type of plan, it gives each insured at least 90 days' notice and offers its other plans of that type.
• Grace period. A health benefit plan allows 30 days to pay premium before termination (304.17A-243).
• Cancellation notice. An insurer cancelling a health benefit plan gives at least 30 days' written notice by first-class mail. Without proper notice, coverage continues until 30 days after notice is given or until replacement coverage starts (304.17A-245).

Required benefits and access

Newborns (304.17A-139):

• A plan covering dependents covers a newborn from the moment of birth, including congenital defects.
• If an added premium is needed, the plan may require notice and payment within 31 days.

Maternity stays (304.17A-145):

• at least 48 hours after a vaginal delivery and 96 hours after a cesarean
• a shorter stay is allowed only if the physician authorizes it, with a postpartum home visit

Dependent children (304.17A-256). A group plan that covers dependents must offer the policyholder one of two options:

• coverage to age 19, plus full-time students to age 25
• coverage of unmarried dependents to age 25

A separate rule covers disabled children past the limiting age (KRS 304.17-310):

• coverage continues for a child who can't support themselves and is chiefly dependent on the policyholder
• proof is due within 31 days of the child reaching the limiting age

Access rules:

• OB/GYN. A woman may get an annual Pap smear from a participating OB/GYN without a referral (304.17A-647).
• Second opinions. A managed care enrollee may get a second opinion from a participating provider for no more than the normal copay or coinsurance (304.17A-520).

Prompt payment (304.17A-702)

• A provider's clean claim must be paid, denied or contested within 30 calendar days of receipt.
• Organ transplant claims get 60 days.
• For other claims, the general rule applies: payment within 30 days of proof, or 12% interest on the settlement (KRS 304.12-235).

Underwriting limits

• Health plans may not require genetic test results or base coverage on an unmanifested genetic condition (304.12-085).
• An HIV test requires written disclosure of intent and the applicant's written informed consent (304.12-013).

Federal rules

The national guide covers the federal ACA rules: essential health benefits, preventive care with no cost-sharing, guaranteed issue, and dependents to 26 under federal law. It also has the 2026 HSA and HDHP limits. The Kentucky options above are stated as the statute writes them. Where federal law requires more, such as dependent coverage to 26, federal law controls.

Common exam traps

• A health benefit plan's grace period is 30 days, and cancellation needs 30 days' notice by first-class mail.
• Fraud or intentional misrepresentation is a valid reason to nonrenew. A claim is not.
• A market withdrawal needs 90 days' notice.
• Newborns are covered from birth. Notice and premium may be required within 31 days.
• Maternity minimums are 48 / 96 hours.
• Clean claims are paid within 30 days, or 60 for transplants.