DEPARTMENT OF INSURANCE

Health and Life Forms and Documents

Health Form Filing Checklists

Pediatric Dental Essential Health Benefit Checklist --

Open Records Requests

P&C Types of Insurance --

Health Form Filing Checklists

Date of Filing Checklist --

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

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

Grandfathered Individual Health Benefit Plan Checklist --

Grandfathered Large Group Health Benefit Plan Checklist --

Grandfathered Small Group Health Benefit Plan Checklist --

Individual Limited Health Benefit Plan Checklist --

Individual Non-Health Benefit Plan Checklist --

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

Provider Agreements for Health Benefit Plans Checklist --

Provider Agreements for Limited Health Benefit Plans Checklist --

Standardized Options Silver 73 CSR Plan Checklist --

Provider Agreements for Limited Health Service Organizations Checklist --

Individual Short-Term Limited Duration Plan Checklist --

Open Records Requests

Public Access Insurance Filings for Rate, Rule, and Form Filing Search --

Health Form Filing Checklists

Standardized Options Bronze Plan Checklist --

Standardized Options Gold Plan Checklist --

Standardized Options Silver 87 CSR Plan Checklist --

Standardized Options Silver 94 CSR Plan Checklist --

Standardized Options Silver Plan Checklist --

Student Health (Blanket) with EHB Checklist --

Open Records Requests

How to File an Open Records Request --

Health Form Filing Checklists

Group and Individual Medicare Supplement Insurance Filing Checklist --

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

Short-Term Nursing Home Insurance Filing Checklist --

General Applications Checklist --

Group Limited Health Benefit Plan Checklist --

Group Non-Health Benefit Plan Checklist --

Long-Term Care Filing Checklist --

Provider Directory Checklist --

Open Records Requests

Open Records Request Form ORR-1 P&C --

Health Form Filing Checklists

Blanket Insurance Checklist --

Health Rate Filing Documents

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

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

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

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

HIPMC-F1 2021 --

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

HIPMC-R36 FORM 2020 --

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

Income and Expense Worksheet --

Health Form Filing Documents

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

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

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

HIPMC-F1 2021 --

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

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

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

Consumer

2025 Anthem Marketplace Service Area Map --

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

2024 Anthem Marketplace Service Area Map --

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

2023 Anthem Marketplace Service Area --

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

Companies Selling In Kentucky's Individual Market --

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

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

Short-Term, Limited Duration Health Insurance --

Provider Related

Clean Claim Form --

KAPER -1 Codes Only (2019) --

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

KAPER Part B Section 1 (2021) --

KAPER Part B Section 2 Fillable (2019) --

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

TMJ Surgical Treatment Preauthorization --

TMJ Nonsurgical Treatment Preauthorization --

Insurer

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

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

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

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

Utilization Review Entities

2024 Utilization Management Review Guide- Full Review --

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

HIPMC-UR-2 Utilization Review Annual Report --

HIPMC-MD-1 - Medical Director Form --

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

Utilization Review Training FAQs --

Utilization Review Training Presentation Slides --

Meeting

Independent Review Entities

IRE Certification Review Guide --

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

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

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

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

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

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

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

Reporting

Prompt Pay Supporting Data Template --

Prompt Payment Spreadsheet (03/2007) --

Prompt Pay Supporting Data Instructions --

Pharmacy Benefit Manager Annual Report Instructions --

HL-MS-1 - Refund Calculation Form --

Medicare Supplement Rate Data Sheet 2010 --

Service Area Expansion Enclosure --

Provider Adequacy and Accessibility Reporting --

New Service Area Enclosure --

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

Data Report Capitation Payment Sheet --

Data Report Health Benefit Plan Questionnaire --

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

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

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

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

HIPMC-DR1 - Data Reporting Manual --

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

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

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

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

Geo Enclosure 1 Revision 513 --

Geo Enclosure 2 Revision 114 --

Limited Health Service Benefit Plan Enclosure 1 --

Limited Health Service Benefit Plan Enclosure 2 --

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

HIPMC-STE-1 Step Therapy Exception Report --

Data Reporting Template-21 --

General Documents (Health)

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

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

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

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

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

Insurance Information for Seniors --

Long Term Care Form Filing Documents

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard Benefit Plan

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

Medicare Supplement Form Filing Documents

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

HL-MS-3 - Disclosure Statements --

HL-MS-4 - Outline of Coverage --

Plan Benefit Chart (Apr 2018) --

HL-MS-6 - Questions for Applications --

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

HL-MS-8 - Notice Regarding Replacement --

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

Life Form Filings

Life Form Filing Process --

General Documents (Life)

2001 CSO Mortality Tables [

]

NOLHGA Assumption Certificate Lincoln --

NOLHGA Generic Notice to Policyholder --

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

Office Form B - Notice Regarding Replacement --

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

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

Annuity Buyer's Guide 2011 --

AIG Consumer FAQ --

Zero Premium --

Options When Your Group Life Coverage Ends --

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

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

Life Buyer's Guide 2011 --

Life Form Filing Checklists

Accelerated Death Benefit Checklist --

Advertising Checklist --

Annuity Checklist --

Basic Application Checklist --

Group Life Insurance Checklist --

Variable Life Checklist --

Life Settlement Checklist --

Long-Term Care Riders Checklist --

Pre-Need Checklist --

Variable Annuity Checklist --

Individual Life Insurance Checklist --

Life Settlement

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

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

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

Verification of Coverage for Life Insurance Policies --

Notice 126 --

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

LS-7 Form Settlement Disclosure --

Life Settlement Consumer Guide --

Viatical Settlement Information Packet --