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Facts for Consumers of Kentucky Health Insurance

Kentucky Consumer Fact Sheet for Health Insurance

It is important to remember that not all insurance plans fall under the jurisdiction of the Kentucky Department of Insurance. Some employer or employee groups purchase health insurance from an insurance company. Others may purchase health coverage from a health maintenance organization (HMO). Both are called fully insured health benefit plans and are regulated by state insurance departments.

However, some employer or employee groups provide what are called self-funded health benefit plans. This means the employer or group sets aside funds and employee premiums each month to pay health claims submitted to the plan. Self-funded plans are under the authority of the U.S. Department of Labor's Pension and Welfare Benefits Administration. These plans are authorized by Congress under the Employee Retirement Income Security Act (ERISA). Some state laws do not apply to ERISA plans and the Kentucky Department of Insurance does not have the authority to investigate complaints about these plans.

If you have a question about the type of plan you have, contact the benefits coordinator at your place of employment.

Consumer tips

Here are some factors to consider when buying health insurance:

Customer Service. Find out how the company services its policyholders. Is there a toll-free customer service number? What happens when you call the company's consumer complaint number?
Complaint history. Has the company had an unusually high number of consumer complaints? Call the Department of Insurance or go to the Web site to access the Complaint Ratio Search. (See contact information on reverse side.)
Licensing status. Call the Department of Insurance to ind out if the company is licensed to do business in Kentucky or go to the department's Web site and do a company search.
Cost. Premiums may vary. Be sure to look at the benefits offered, as well as the cost.
Financial stability. Financial stability helps ensure that a company can pay its claims. The Department of Insurance establishes requirements that each company must follow and continually monitors the financial stability of insurance companies operating in the state. Independent organizations also rate financial stability.

Types of health insurance plans

Traditional fee-for-service (FFS) plans - Allows an individual to go to the doctor of his or her choice and then submit the claim to the insurer. These plans are becoming rare.
Health Maintenance Organization (HMO) - Provides services through a network of doctors, hospitals, laboratories and other providers. The HMO pays providers a monthly amount regardless of the services performed. When you enroll in an HMO, you will select one of the doctors as your primary care physician (PCP) to manage all of your health care. Depending on your plan, you may have to get a referral from your PCP before seeing a specialist for additional care.
Preferred provider organization (PPO) - A group of doctors, hospitals and other providers who have agreed to provide services to members of a health plan so you can use providers who are not on the PPO list. To encourage you to use the preferred providers, however, they charge lower out-of-pocket expenses than if you use a provider not on the list.
Point of Service (POS) - A POS is similar to an HMO in that you select a primary care physician to manage your care. A POS also gives you the option to see a provider outside the network. However, if you leave the network, the plan pays at a reduced rate and you will have more out-of-pocket expenses.

Coverage by Region:

Resources:

Articles:

Kentucky Consumers Guide to Health Insurance:

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