RELATES TO:
KRS
304.17A-005,
304.17A-320,
304.17A-330,
304.17A-750
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
304.2-110(1) authorizes the
commissioner to promulgate reasonable administrative regulations necessary for,
or as an aid to, the effectuation of any provision of the Kentucky Insurance
Code as defined in
KRS
304.1-010.
KRS
304.17A-330 authorizes the commissioner to
prescribe the format for reporting the information required by
KRS
304.17A-330. This administrative regulation
establishes the data elements and the format for submitting annual reports to
the Department of Insurance.
Section
1. Definitions.
(1)
"Association" is defined by
KRS
304.17A-005(1).
(2) "Electronic format" means an electronic
copy of a Microsoft Excel Spreadsheet.
(3) "Health benefit plan" means a health
benefit plan as defined by
KRS
304.17A-005(22) and issued
within Kentucky to a Kentucky resident.
(4) "Insurance purchasing outlet" is defined
by
KRS
304.17A-750(4).
(5) "Insurer" is defined by
KRS
304.17A-005(29).
(6) "Market segment" means the portion of the
market covering one (1) of the following:
(a)
Individual;
(b) Small
group;
(c) Large group;
(d) Group association;
(e) Individual association;
(f) Self-insured employer-organized
association; or
(g) Insurance
purchasing outlet.
(7)
"Medical service" means the service that was provided by a health care provider
to a member of a health benefit plan.
(8) "Member" means a covered person, as
defined by
KRS
304.17A-500(3).
(9) "Member month" means a period of time
that represents each month that a member or subscriber, depending upon the data
request, is enrolled in a health benefit plan.
(10) "Self-insured employer-organized
association" means an association that holds a certificate of filing pursuant
to
KRS
304.17A-320.
(11) "Subscriber" means the following:
(a) In the individual market, the number of
health benefit plan policyholders; or
(b) In the small group, large group,
individual association, group association, self-insured employer-organized
association, or insurance purchasing outlet market, the number of health
benefit plan certificate holders.
(12) "Total unduplicated covered persons"
means the total number of subscribers and their dependents covered by a health
benefit plan at any time during the reporting year.
Section 2. Data Reporting Requirements.
(1) Beginning with the report due by July 31,
2004, and within the time frame prescribed by
KRS
304.17A-330, an insurer authorized to write
health insurance in this state, a self-insured employer-organized association,
and an insurance purchasing outlet shall submit the following reports regarding
health benefit plans to the Department of Insurance:
(a) Annual Report 1 - Insurer Information
Report;
(b) Annual Report 2 -
Premium and Enrollment Report as Member Months;
(c) Annual Report 3 - Demographic Report as
Member Months;
(d) Annual Report 4
- Billed Charge and Paid Claim Report;
(e) Annual Report 5 - Medical Service Cost
Report by Market Segment;
(f)
Annual Report 6 - Medical Service Cost Report by Product Type;
(g) Annual Report 7 - Policy Discontinuance
Reason Report;
(h) Annual Report 8
- Mental Health Parity Report by Market Segment; and
(i) Annual Report 9 - Mental Health Parity
Report by Product Type.
(2) An entity described in subsection (1) of
this section with more than 500 total unduplicated covered persons shall submit
all of the reports listed in subsection (1)(a) through (i) of this
section.
(3) An entity described in
subsection (1) of this section with 500 or less total unduplicated covered
persons shall submit only the report listed in subsection (1)(a) of this
section.
(4) An insurer, a
self-insured employer-organized association, or an insurance purchasing outlet,
who ceases operations in Kentucky shall submit the reports required by
subsection (1) of this section to the Department of Insurance within 120 days
after cessation.
(5) The reports
required pursuant to subsection (1) of this section are contained in the Data
Reporting Manual, HIPMC-DR-1", and the reports shall:
(a) Be submitted in an electronic format;
and
(b) Contain the prescribed data
elements and information in the order prescribed by the Data Reporting
Manual.
Section
3. Incorporated by Reference.
(1)
"Data Reporting Manual", HIPMC-DR-1, 09/21 is incorporated by
reference.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law, at the
Kentucky Department of Insurance, 500 Mero Street, Frankfort, Kentucky 40601,
Monday through Friday, 8 a.m. to 4:30 p.m. This material is also available on
the department's internet Web site at
https://insurance.ky.gov/ppc/CHAPTER.aspx.