Form HL-F11 "Health Summary Sheet - Form Filings" - Kentucky

What Is Form HL-F11?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HL-F11 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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KY DEPARTMENT OF INSURANCE
HEALTH SUMMARY SHEET – FORM FILINGS
1. COMPANY NAME:
NAIC#_
D/B/A:_
2. POLICY FORM NUMBER(S):
3.
COMPANY FILING NUMBER (If Applicable):
4.
PRODUCT NAME:
5.
PRODUCT TYPE:
FFS
PPO
POS
HMO (Must be licensed as an HMO)
EPO
Other _______________________________________
6.
PPO OR POS PLAN REQUIRES OUT-OF-NETWORK REFERRAL:
YES
NO
7.
MARKET SEGMENT:
LG. GROUP
SM. GROUP
ASSOCIATION
INDIVIDUAL
EMPLOYER ORGANIZED ASSOCIATION
SELF INSURED EMPLOYER ORGAIZED ASSOCIATION (MEWA)
ANSWER THE FOLLOWING QUESTIONS FOR HEALTH BENEFIT PLAN FILINGS:
8.
PRODUCT INCLUDES A MINIMUM LOSS RATIO GUARANTEE BENEFIT
YES
NO
(KRS 304.17A-095(6))
9.
THIS FILING IS:
A High Deductible Health Plan with Health Savings Account
( )
( )
A Conversion Policy
( )
Other ____________________________________________
10. THIS FILING IS:
Grandmothered/Transitional
( )
Grandfathered Plan
( )
Non-Grandfathered
On Exchange
Off Exchange
( )
ANSWER THE FOLLOWING FOR LIMITED HEALTH SERVICE BENEFIT PLAN FILINGS:
11. THIS FILING IS:
( )
• A New Limited Health Service Benefit Plan
• A Revision to a Previously Filed Limited Health Service Benefit Plan
( )
• Short Term Nursing
( )
12. FOR DENTAL ONLY:
On Exchange
Off Exchange
Exchange Certified
Stand-Alone Dental
COMPLETED BY:
HL-F11 (07/2020)
KY DEPARTMENT OF INSURANCE
HEALTH SUMMARY SHEET – FORM FILINGS
1. COMPANY NAME:
NAIC#_
D/B/A:_
2. POLICY FORM NUMBER(S):
3.
COMPANY FILING NUMBER (If Applicable):
4.
PRODUCT NAME:
5.
PRODUCT TYPE:
FFS
PPO
POS
HMO (Must be licensed as an HMO)
EPO
Other _______________________________________
6.
PPO OR POS PLAN REQUIRES OUT-OF-NETWORK REFERRAL:
YES
NO
7.
MARKET SEGMENT:
LG. GROUP
SM. GROUP
ASSOCIATION
INDIVIDUAL
EMPLOYER ORGANIZED ASSOCIATION
SELF INSURED EMPLOYER ORGAIZED ASSOCIATION (MEWA)
ANSWER THE FOLLOWING QUESTIONS FOR HEALTH BENEFIT PLAN FILINGS:
8.
PRODUCT INCLUDES A MINIMUM LOSS RATIO GUARANTEE BENEFIT
YES
NO
(KRS 304.17A-095(6))
9.
THIS FILING IS:
A High Deductible Health Plan with Health Savings Account
( )
( )
A Conversion Policy
( )
Other ____________________________________________
10. THIS FILING IS:
Grandmothered/Transitional
( )
Grandfathered Plan
( )
Non-Grandfathered
On Exchange
Off Exchange
( )
ANSWER THE FOLLOWING FOR LIMITED HEALTH SERVICE BENEFIT PLAN FILINGS:
11. THIS FILING IS:
( )
• A New Limited Health Service Benefit Plan
• A Revision to a Previously Filed Limited Health Service Benefit Plan
( )
• Short Term Nursing
( )
12. FOR DENTAL ONLY:
On Exchange
Off Exchange
Exchange Certified
Stand-Alone Dental
COMPLETED BY:
HL-F11 (07/2020)