CHAPTER 20:06:21

LONG-TERM CARE INSURANCE

Section

20:06:21:01        Definitions.

20:06:21:01.01   Nature of care -- How defined.

20:06:21:01.02   Service providers -- How defined.

20:06:21:01.03   Long-term care insurance.

20:06:21:01.04   Similar policy forms.

20:06:21:01.05   Treatment of accelerated benefits in life insurance.

20:06:21:01.06   Claim and clean claim -- Defined.

20:06:21:02        Minimum standards for long-term care insurance policies.

20:06:21:02.01   Annuity policies with long-term care benefits subject to waiting period.

20:06:21:03        Renewability of group policies -- Required disclosures.

20:06:21:04        Permissible exclusions from coverage.

20:06:21:05        Loss ratios.

20:06:21:05.01   Relation of benefits to premium for accelerated death benefit on life insurance.

20:06:21:06        Cost-of-living adjustments -- Basis.

20:06:21:06.01   Cost-of-living adjustments -- Minimum standards.

20:06:21:06.02   Group cost-of-living adjustments -- Exceptions.

20:06:21:06.03   Cost-of-living adjustments -- Continuation of benefit increases.

20:06:21:06.04   Cost-of-living adjustments -- Automatic increases -- Conspicuous offer of constant premium.

20:06:21:06.05   Cost-of-living adjustments -- Rejection by policyholder.

20:06:21:07        Applicability of rules to long-term care insurance riders.

20:06:21:08        "Medically necessary" defined.

20:06:21:09        Basis for conversion of coverage from group defined.

20:06:21:10        Converted policy from group defined.

20:06:21:11        Converted policy from group -- Time allowed for written application.

20:06:21:12        Converted policy from group -- Calculation of policy premium.

20:06:21:13        Continuation or conversion is mandatory -- Exceptions.

20:06:21:14        Converted policy from group to individual -- Reduction of benefits -- Exception.

20:06:21:15        Converted policy from group -- Benefits payable.

20:06:21:16        Converted policy from group -- Eligibility for coverage of relatives.

20:06:21:17        Converted policy from group -- Managed care plan defined.

20:06:21:18        Discontinuance and replacement of a group policy.

20:06:21:19        Premium increase prohibitions.

20:06:21:20        Lapse or termination notice required.

20:06:21:21        Lapse or termination for payment through payroll or pension deduction plan.

20:06:21:22        Lapse or termination for nonpayment of premium.

20:06:21:23        Disclosure of renewability.

20:06:21:24        Disclosure of payment of benefits based on certain standards.

20:06:21:25        Disclosure of limitations on preexisting conditions.

20:06:21:26        Disclosure of other limitations or conditions on eligibility for benefits.

20:06:21:26.01   Notice to claimants -- Temporary leave.

20:06:21:27        Outline of coverage.

20:06:21:28        Outline of coverage -- Standard format.

20:06:21:28.01   Applications -- Questions about replacement.

20:06:21:29        Replacement notices.

20:06:21:30        Filing requirements for advertising -- Exemption.

20:06:21:31        Standards for marketing -- Requirements.

20:06:21:32        Standards for marketing -- Prohibited practices.

20:06:21:33        Standards for marketing -- Associations.

20:06:21:34        Extension of benefits.

20:06:21:35        Basis for continuation or conversion from group coverage required.

20:06:21:36        Basis for continuation of coverage from group defined.

20:06:21:37        Reinstatement.

20:06:21:38        Disclosure of riders and endorsements.

20:06:21:39        Disclosure of tax consequences.

20:06:21:40        Applications -- Health and medication questions.

20:06:21:41        Applications -- Notice about incorrect answers.

20:06:21:42        Policies -- Notice about incorrect answers on applications.

20:06:21:43        Elderly applicants -- Required information.

20:06:21:44        Applications -- Delivery.

20:06:21:44.01   Repealed.

20:06:21:45        Records of rescissions -- Maintaining and filing records.

20:06:21:46        Minimum standards for home health and community care benefits.

20:06:21:47        Policy summary for individual life insurance policy containing long-term care benefits.

20:06:21:48        Monthly report to policyholder.

20:06:21:49        Incontestability period.

20:06:21:50        Assisted living center or facility defined.

20:06:21:51        Assisted living centers -- Minimum benefit standards.

20:06:21:52        Reporting requirements for insurers.

20:06:21:53        Appropriateness of recommended purchase or replacement.

20:06:21:53.01   Suitability standards.

20:06:21:53.02   Suitability -- Long-term care insurance personal worksheet.

20:06:21:53.03   Suitability -- Response letter.

20:06:21:53.04   Suitability -- Policies not included.

20:06:21:53.05   Suitability -- Overinsurance.

20:06:21:54        Requirement to deliver shopper's guide.

20:06:21:55        Standards for benefit triggers.

20:06:21:56        Additional standards for benefit triggers for qualified long-term care insurance contracts.

20:06:21:57        Nonforfeiture benefits.

20:06:21:58        Nonforfeiture benefit requirement.

20:06:21:59        Electronic enrollment for group policies.

20:06:21:60        Required disclosure of rating practices to consumers -- Rate stabilization.

20:06:21:61        Initial filing requirements.

20:06:21:62        Reserve standards.

20:06:21:63        Premium rate schedule increases -- Notice of pending increase.

20:06:21:64        Premium rate schedule increase requirements.

20:06:21:65        Premium rate schedule increases -- Review by the director

20:06:21:66        Premium rate schedule increases -- Adverse lapsation.

20:06:21:67        Premium rate schedule increases -- Policies to which does not apply.

20:06:21:68        Premium rate schedule increases -- Group insurance policies.

20:06:21:69        Premium rate schedule increases -- Adoption of rules.

20:06:21:70        Premium rate schedule increases -- Exceptional increases.

20:06:21:71        Permitted compensation arrangements.

20:06:21:72        Disclosure to applicant for a claim denial.

20:06:21:73        Providers in a different state.

20:06:21:74        Agent training required to market long-term care plans.

20:06:21:75        Insurers required to verify agent training and maintain records.

20:06:21:76        Long-term care partnership policies -- Inflation protection requirements.

20:06:21:77        Long-term care partnership policies -- Required policy disclosures.

20:06:21:78        Long-term care partnership policies -- Filing requirements.

20:06:21:79        Long-term care -- Minimum benefit requirements.

20:06:21:80        Long-term care partnership policies -- Policy amendments.

20:06:21:81        Long-term care policies -- Policy amendments.

20:06:21:82        Availability of new services or providers.

20:06:21:83        Policies issued considered exchanges.

20:06:21:84        Policies offered through employers, labor unions, and associations.

20:06:21:85        Applicability of new provider or service requirements.

20:06:21:86        Right to reduce coverage and lower premiums.

20:06:21:87        Authorized representative.

20:06:21:88        Notice to insured.

20:06:21:89        Internal appeal.

20:06:21:90        Internal appeal notice requirements.

20:06:21:91        Independent review of benefit trigger determination.

20:06:21:92        Independent review process.

20:06:21:93        Additional appeal information.

20:06:21:94        Independent review notification.

20:06:21:95        Independent review organization selection.

20:06:21:96        Review of information.

20:06:21:97        Additional information to independent review.

20:06:21:98        Process if determination overturned.

20:06:21:99        Review decision requirements.

20:06:21:100      Acceptance of state certification.

20:06:21:101      Certification of long-term care insurance independent review organizations.

20:06:21:102      Maintenance of records and reporting obligations by independent review organizations.

20:06:21:103      Additional rights.

20:06:21:104      Applicability.

20:06:21:105      Payment of clean claim.

20:06:21:106      Claim timeframes.

20:06:21:107      Unpaid claims.

20:06:21:108      Violations.

Appendix A   Outline of Coverage.

Appendix B   Replacement of Individual Accident and Sickness or Long-Term Care Coverage.

Appendix C   Replacement of Accident and Sickness or Long-Term Care Coverage.

Appendix D   Rescission Reporting Form.

Appendix E    Personal Worksheet.

Appendix F    Disclosure Form.

Appendix G   Response Letter.

Appendix H   Sample Claims Denial Format.

Appendix I     Potential Rate Increase Disclosure Form.

Appendix J    Replacement and Lapse Reporting Form.

Appendix K   Partnership Disclosure Form.

Appendix L    Partnership Certification Form.

Appendix M  Guidelines for Long-Term Care Independent Review Entities.