806 KAR 17:240. Data reporting requirements.
RELATES TO: KRS 304.17A-320, 304.17A-330
STATUTORY AUTHORITY: KRS 304.2-110(1), 304.17A-330
NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) authorizes the executive director 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 executive director 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 Office of Insurance.
Section 1. Definitions. (1) "Association" is defined in KRS 304.17A-005(1).
(2) "Covered person" is defined in KRS 304.17A-500(3).
(3) "Electronic format" means the use of any of the following mechanisms for the submission of data to the Office of Insurance:
(a) A three and one-half (3.5) inch diskette; or
(b) CD-ROM in a Microsoft Excel spreadsheet.
(4) "Health benefit plan" means a health benefit plan as defined in KRS 304.17A-005(22) and issued within Kentucky to a Kentucky resident.
(5) "Insurance purchasing outlet" is defined in KRS 304.17A-750(4).
(6) "Insurer" is defined in KRS 304.17A-005(27).
(7) "Market segment" means the portion of the market covering one (1) of the following:
(b) Small group;
(c) Large group;
(d) Group association;
(e) Individual association;
(f) Self-insured employer organized association; or
(g) Insurance purchasing outlet.
(8) "Medical service" means the service that was provided by a health care provider to a member of a health benefit plan.
(9) "Member" means a covered person.
(10) "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.
(11) "Self-insured employer organized association" means an association that holds a certificate of filing pursuant to KRS 304.17A-320.
(12) "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.
(13) "Total unduplicated covered persons" means the total number of subscribers and their dependents covered by a health 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 Office 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; and
(g) Annual Report 7 - Policy Discontinuance Reason Report.
(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 (g) 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 Office 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 (06/03)", 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 (06/03)" is incorporated by reference.
(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. This material is also available on the office’s internet Web site at http://doi.ppr.ky.gov. (27 Ky.R. 1695; 2190; 2452; eff. 3-19-2001; 30 Ky.R. 103; 657; 10-31-2003; TAm eff. 8-9-2007.)