Ky. Rev. Stat. § 304.17A-591

Current through 2024 Ky. Acts ch. 225

Section 304.17A-591 - [Effective 1/1/2025] Definitions for KRS 304.17A-591 to 304.17A-599

As used in KRS 304.17A-591 to 304.17A.599:

(1) "Cost sharing" means the cost to an insured under a health plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan;

(2) "Health plan":

(a) Except as provided in paragraph (c) of this subsection, means any policy, certificate, contract, or plan that offers or provides coverage in this state for pharmacy or pharmacist services, whether the coverage is by direct payment, reimbursement, or otherwise;

(b) Includes a health benefit plan; and

(c) Does not include:

1. A policy, certificate, contract, or plan that:

a. Offers or provides services under KRS Chapter 205; or

b. Is established by the Teachers' Retirement System pursuant to KRS 161.675 solely for the purpose of providing coverage to Medicare-eligible annuitants and dependents of annuitants;

2. A self-insured health plan provided by a hospital or health system to its employees and dependents of employees if the hospital or health system owns a pharmacy;

3. A prescription drug plan established under Medicare Part D; or

4. Student health insurance offered by a Kentucky-licensed insurer under written contract with a university or college whose students it proposes to insure;

(3) "Insured" means any individual covered under a health plan;

(4) "Insurer":

(a) Means any of the following persons that offer or issue a health plan:

1. An insurance company;

2. A health maintenance organization;

3. A limited health service organization;

4. A self-insurer, including a governmental plan, church plan, or multiple employer welfare arrangement;

5. A provider-sponsored integrated health delivery network;

6. A self-insured employer-organized association;

7. A nonprofit hospital, medical-surgical, dental, and health service corporation; or

8. Any other third-party payor that is:

a. Authorized to transact health insurance business in this state; or

b. Not exempt by federal law from regulation under the insurance laws of this state; and

(b) Includes any person that has contracted with a state or federal agency to provide coverage in this state under a health plan;

(5) "Pharmacy" has the same meaning as in KRS 315.010;

(6)

(a) "Pharmacy affiliate" means a pharmacy, including a specialty pharmacy, that owns or controls, is owned or controlled by, or is under common ownership or common control with an insurer, pharmacy benefit manager, or other administrator of pharmacy benefits.

(b) As used in this subsection:

1. "Common control" includes sharing common management or managers and having common members on boards of directors; and

2. "Control" may be direct or indirect through one (1) or more intermediaries;

(7) "Pharmacy benefit manager" has the same meaning as in KRS 304.9-020; and

(8) "Pharmacy or pharmacist services":

(a) Means any health care procedures, treatments within the scope of practice of a pharmacist, or services provided by a pharmacy or pharmacist; and

(b) Includes the sale and provision of the following by a pharmacy or pharmacist:

1. Prescription drugs as defined in KRS 315.010; and

2. Home medical equipment as defined in KRS 309.402.

KRS 304.17A-591

Added by 2024 Ky. Acts ch. 104,§ 1, eff. 1/1/2025.