DEPARTMENT OF INSURANCE

Health and Life Forms and Documents

Health Form Filing Checklists

Pediatric Dental Essential Health Benefit Checklist - 467K

Provider Directory Checklist - 332K

Date of Filing Checklist - 411K

Non-Grandfathered Individual & Conversion Health Benefit Plan (Major Medical Coverage) Checklist - 782K

Non-Grandfathered Large Group Health Benefit Plan (Major Medical Coverage) Checklist - 622K

Grandfathered Individual Health Benefit Plan Checklist - 600K

Grandfathered Large Group Health Benefit Plan Checklist - 591K

Grandfathered Small Group Health Benefit Plan Checklist - 575K

Individual Limited Health Benefit Plan Checklist - 507K

Individual Non-Health Benefit Plan Checklist - 503K

Non-Grandfathered Small Group Health Benefit (Major Medical Coverage) Plan Checklist - 738K

Provider Agreements for Health Benefit Plans Checklist - 369K

Provider Agreements for Limited Health Benefit Plans Checklist - 410K

Standardized Options Silver 73 CSR Plan Checklist - 811K

Provider Agreements for Limited Health Service Organizations Checklist - 416K

Individual Short-Term Limited Duration Plan Checklist - 582K

Standardized Options Bronze Plan Checklist - 809K

Standardized Options Gold Plan Checklist - 809K

Standardized Options Silver 87 CSR Plan Checklist - 811K

Standardized Options Silver 94 CSR Plan Checklist - 811K

Standardized Options Silver Plan Checklist - 809K

Student Health (Blanket) with EHB Checklist - 716K

Group and Individual Medicare Supplement Insurance Filing Checklist - 292K

Group and Individual Medicare Supplement Insurance Filing Checklist - Attachment 1 - 50K

Short-Term Nursing Home Insurance Filing Checklist - 20K

General Applications Checklist - 425K

Group Limited Health Benefit Plan Checklist - 471K

Group Non-Health Benefit Plan Checklist - 480K

Long-Term Care Filing Checklist - 87K

Blanket Insurance Checklist - 512K

Health Rate Filing Documents

HIPMC-R32 (07/2008) Health Benefit Plan Rate Filing - 26K

HIPMC-R33 (12/2000) - Health Benefit Plan Regions - 6K

HIPMC-R34 (07/2008) Attachment A - Certification - 7K

HIPMC-RF25 (07/2008) - Basic Health Benefit Plan Summary Sheet - Form and Rate Filings - 10K

HIPMC-F1 2021 - 180K

Form HIPMC-F11, Health Rate Summary Sheet – Form Filings - 154K

HIPMC-R36 FORM 2020 - 111K

HIPMC-R-4 Individual Health Forms Actuarial Certification Form - 54K

Income and Expense Worksheet - 26K

Health Form Filing Documents

HIPMC-RF25 (07/2008) - Basic Health Benefit Plan Summary Sheet - Form and Rate Filings - 10K

HIPMC-F2 Health Policy Forms Filing Certification Privilege Program Form - 30K

HIPMC-F35 - Health Benefit Plan Summary Sheet - Form Filings - 51K

HIPMC-F1 2021 - 180K

HIPMC-R1 (7-2000) - Risk-Sharing Arrangement Information Sheet - 5K

HIPMC-F-16 Additional Health Info Request Form - 96K

HIPMC-F37 (07/2008) - Limited Health Service Benefit Plan Summary Sheet - Form Filings - 51K

Consumer

2026 Anthem, Molina-Passport, WellCare-Ambetter Service Area Map - 152K

2025 Anthem Marketplace Service Area Map - 172K

2025 CareSource, Molina-Passport, WellCare Marketplace Service Area Map - 180K

2024 Anthem Marketplace Service Area Map - 172K

2024 CareSource, Molina-Passport, WellCare Marketplace Service Area Map - 179K

2023 Anthem Marketplace Service Area - 166K

2023 CareSource, Molina-Passport, WellCare Marketplace Service Area - 168K

Companies Selling In Kentucky's Individual Market - 41K

Companies Selling Short-Term Major Medical Insurance in Kentucky - 12K

Companies Selling Association, Large Group, Small Group and Individual Health Insurance in Kentucky - 475K

Short-Term, Limited Duration Health Insurance - 442K

Provider Related

Clean Claim Form - 129K

KAPER -1 Codes Only (2019) - 303K

KAPER-1 Part A- Application (2019) - 2M

KAPER Part B Section 1 (2021) - 615K

KAPER Part B Section 2 Fillable (2019) - 375K

Kentucky Application for Provider Evaluation and Re-evaluation KAPER-1 (2019) - 3M

TMJ Surgical Treatment Preauthorization - 35K

TMJ Nonsurgical Treatment Preauthorization - 32K

Insurer

HIPMC-CC1 (January 2006) - Certificate of Individual Health Plan Coverage - 9K

Independent Review Information - List of IRE's certified to perform external reviews - 120K

HIPMC-MD1 (10/2000) - Medical Director Report Form - 80K

HIPMC-STN-01 Outline of Coverage for Shot-term Care - 125K

Utilization Review Entities

2024 Utilization Management Review Guide- Full Review - 650K

HIPMC-UR-1 - Utilization Review Registration Application - 315K

HIPMC-UR-2 Utilization Review Annual Report - 188K

HIPMC-MD-1 - Medical Director Form - 83K

2020 Utilization Management Limited Self-Funded Review Guide Interactive - 360K

Utilization Review Training FAQs - 173K

Utilization Review Training Presentation Slides - 3M

Meeting

Independent Review Entities

IRE Certification Review Guide - 410K

HIPMC-IRE-1 - Application for Certification of an Independent Review Entity - 271K

HIPMC-IRE-2 - Assignment of Independent Review Entity Form - 129K

HIPMC-IRE-3 - External Review Decision Notification Form - 100K

HIPMC-IRE-4 - Data Reporting For Independent Review Entities - 98K

HIPMC-IRE-5 - Approval of an External Review Fee in excess of $800 - 94K

HIPMC-IRE-6 - External Review Information Face Sheet - 139K

Independent Review Information - List of IRE's certified to perform external reviews - 120K

Reporting

Prompt Pay Supporting Data Template - 15K

Prompt Payment Spreadsheet (03/2007) - 27K

Prompt Pay Supporting Data Instructions - 793K

Pharmacy Benefit Manager Annual Report Instructions - 642K

HL-MS-1 - Refund Calculation Form - 165K

Medicare Supplement Rate Data Sheet 2010 - 13K

Service Area Expansion Enclosure - 9K

Provider Adequacy and Accessibility Reporting - 91K

New Service Area Enclosure - 9K

HIPMC-BHP1 (07/2008) - Basic Health Benefit Plan Annual Report - 13K

Data Report Capitation Payment Sheet - 16K

Data Report Health Benefit Plan Questionnaire - 52K

DIPR-PPR1 (07/2018) - Prompt Pay Reporting Manual - 168K

HIPMC-LTC 11 (09/2008) - Replacement and Lapse Reporting Form - 11K

HIPMC-LTC 3 (09/2008) - Rescission Reporting Form - 8K

HIPMC-LTC 4 (09/2001) - Claims Denial Reporting Form - 60K

HIPMC-DR1 - Data Reporting Manual - 560K

HIPMC-GAP ERF-M-1 & A-1 Monthly and Annual Report Format - 98K

HIPMC-GAP-AFF-1 (06/01) - Guaranteed Acceptance Program (GAP) Affidavit - 6K

HIPMC-GAP-C-1GAP (12-2000) - Guaranteed Acceptance Program (GAP) Certification Form - 6K

HIPMC-GAPQR-2 (04/01) - Supporting Insurer's and Stop-Loss Carrier's Quarterly Report - 6K

Geo Enclosure 1 Revision 513 - 143K

Geo Enclosure 2 Revision 114 - 10K

Limited Health Service Benefit Plan Enclosure 1 - 115K

Limited Health Service Benefit Plan Enclosure 2 - 9K

HIPMC-STE-1 Step Therapy Exceptions Annual Report Instructions - 158K

HIPMC-STE-1 Step Therapy Exception Report - 20K

Data Reporting Template-21 - 39K

General Documents (Health)

Appealing a Denial From Your Health Benefit Plan - A How-To Guide - 48K

Appealing a Denial From Your Health Benefit Plan - Expanded Version - 349K

Appendix A: Notice to Applicant Regarding Replacement of Health Insurance - 76K

Kentucky Long-Term Care Partnership Insurance Program Implementation Update (12/2008) - 57K

Department of Labor's Model Continuation Coverage Election Notice - 11K

Insurance Information for Seniors - 3M

Long Term Care Form Filing Documents

HIPMC-LTC 1 (09/2008) - Personal Worksheet - 16K

HIPMC-LTC 10 (09/2008) - Disclosures and Language for Long-term Care Policies and Certificates - 9K

HIPMC-LTC 2 (09/2008) - Potential Rate Increase Disclosure Form - 24K

HIPMC-LTC 5 (09/2008) - Things You Should Know Before You Buy Long -Term Care Insurance - 14K

HIPMC-LTC 6 (09/2008) - Suitability Letter - 17K

HIPMC-LTC 7 (09/2008) - Outline of Coverage - 17K

The Kentucky Long -Term Care Partnership Insurance Program Notice - 162K

HIPMC-LTC 9 (09/2008) - Notice to Applicant Regarding Replacement of Group Accident and Sickness or Long-Term Care Insurance - 9K

LTCPIP-1 - Important Information About Your Kentucky Long-Term Care Partnership Insurance - 114K

LTCPIP-3 - Important Notice of Offer to Exchange - 74K

LTCPIP-4 - Long-term Care Partnership Insurance (LTCPI) Program Statement of Benefits Paid - 41K

LTCPIP-2- The Kentucky Long Term Care Partnership Insurance Program Notice - 162K

HIPMC-LTC 8 (09/2008) - Notice to Applicant Regarding Replacement of Ind Accident and Sickness or Long-Term Care Insurance - 12K

Standard Benefit Plan

Kentucky Standard Health Benefit Plan (06/2011) - 671K

Medicare Supplement Form Filing Documents

HL-MS-2 - Form for Reporting Medicare Supplement Policies - 44K

HL-MS-3 - Disclosure Statements - 175K

HL-MS-4 - Outline of Coverage - 487K

HL-MS-5 - Kentucky Medicare Supplement Comparison Statement - 40K

HLMS-9 2023 --

HL-MS-7 - Statement Regarding Medicare Supplement Policies - 47K

HL-MS-8 - Notice Regarding Replacement - 69K

Plan Benefit Chart (Apr 2018) - 667K

HL-MS-6 - Questions for Applications - 77K

Life Form Filings

Life Form Filing Process - 154K

General Documents (Life)

2001 CSO Mortality Tables [

]

NOLHGA Assumption Certificate Lincoln - 12K

NOLHGA Generic Notice to Policyholder - 25K

Office Form A - Replacement Of Life Insurance Or Annuities (Applicant and Agent) - 34K

Office Form B - Notice Regarding Replacement - 11K

Office Form C - Replacement Of Life Insurance Or Annuities - 33K

Notice of Rights as an Owner of a Life Insurance Policy - 120K

Annuity Buyer's Guide 2011 - 234K

AIG Consumer FAQ - 50K

Zero Premium - 87K

Options When Your Group Life Coverage Ends - 299K

Department of Defense Instruction Number 1344.07, Personal Commercial Solicitation on DoD Installations - 213K

Department of Defense Form 2885, Personal Commercial Solicitation Evaluation - 350K

Life Buyer's Guide 2011 - 260K

Life Form Filing Checklists

Accelerated Death Benefit Checklist - 29K

Advertising Checklist - 21K

Annuity Checklist - 42K

Basic Application Checklist - 21K

Group Life Insurance Checklist - 22K

Variable Life Checklist - 42K

Life Settlement Checklist - 22K

Long-Term Care Riders Checklist - 22K

Pre-Need Checklist - 24K

Variable Annuity Checklist - 41K

Individual Life Insurance Checklist - 47K

Life Settlement

LS2 (7/2008) Individual Mortality Report - For Insureds Only - 24K

LS3 (7/2008) Life Settlement Provider Report - All States and Territories - 21K

LS6 (7/2008) Life Settlement Provider Certification Form - 8K

Verification of Coverage for Life Insurance Policies - 172K

Notice 126 - 120K

LS1 (7/2008) Life Settlement Provider Report - For Insureds Only - 24K

LS-7 Form Settlement Disclosure - 102K

Life Settlement Consumer Guide - 201K

Viatical Settlement Information Packet - 603K