CHAPTER Ins 3600 LONG-TERM CARE INSURANCE
Statutory Authority:
RSA 400-A:15, I; RSA 415-D:12
PART Ins 3601 LONG-TERM
CARE INSURANCE
Ins 3601.01 Purpose. The
purpose of this rule is to implement RSA 415-D, to promote the public interest,
to promote the availability of long-term care insurance coverage, to protect
applicants for long-term care insurance, as defined, from unfair or deceptive
sales or enrollment practices, to facilitate public understanding and
comparison of long-term care insurance coverages, and to facilitate flexibility
and innovation in the development of long-term care insurance.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.02 Applicability and
Scope. Except as otherwise specifically provided, this rule
applies to all long-term care insurance policies, including qualified long-term
care contracts and life insurance policies that accelerate benefits for
long-term care delivered or issued for delivery in this state on or after the
effective date by insurers; fraternal benefit societies; nonprofit
health, hospital and medical service
corporations; prepaid health plans; health maintenance organizations and all
similar organizations. Certain provisions of this rule apply only to
qualified long-term care insurance contracts as noted.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.03 Definitions. For the purpose of this rule, the terms “long-term care
insurance”, “qualified long-term care insurance”, “group long-term care
insurance”, “commissioner”, “applicant”, “policy”, and “certificate” shall have
the meanings set forth in RSA 415-D:3. In addition, the following
definitions apply:
(a) “Benefit
trigger”, for the purposes of independent review, means a contractual provision
in the insured’s policy of long-term care insurance, conditioning the payment
of benefits on a determination of the insured's ability to perform activities
of daily living and on cognitive impairment. For purposes of a
tax-qualified long-term care insurance contract, as defined in section 7702B of
the Internal Revenue Code of 1986, as amended, “benefit trigger” shall include
a determination by a licensed health care practitioner that an insured is a
chronically ill individual;
(b) (1) “Exceptional
increase” means only those increases filed by an insurer as exceptional for
which the commissioner determines the need for the premium rate increase is
justified due to changes in laws or rules applicable to long-term care
coverage in this state;
(2) Except as
provided in Ins 3601.19, exceptional
increases are subject to the same requirements as other premium rate schedule
increases;
(3) The
commissioner may request a review by an independent actuary or a professional
actuarial body of the basis for a request that an increase be considered an
exceptional increase; and
(4) The
commissioner, in determining that the necessary basis for an exceptional
increase exists, shall also determine any potential offsets to higher
claims costs;
(c) “Incidental”, as used in Ins 3601.19(k), means that the value of the long-term
care benefits provided is less than 10 percent of the total value of the
benefits provided over the life of the policy. These values shall be
measured as of the date of issue;
(d) “Independent review organization”
means an organization that conducts independent review of long-term care benefit
trigger decisions;
(e) “Licensed health care
professional” means an individual qualified by education and experience in an
appropriate field to determine, by record review, an insured’s actual
functional or cognitive impairment;
(f) “Qualified actuary” means a
member in good standing of the American Academy of Actuaries;
and
(g) “Similar policy forms”
means all of the long-term care insurance
policies and certificates issued by an insurer in the same long-term care
benefit classification as the policy form being
considered. Certificates of groups that meet the definition in RSA
415-D:3, IV(a) are not considered similar to certificates
or policies otherwise issued as long-term care insurance but are
similar to other comparable certificates with the same long-term care benefit
classifications. For purposes of determining similar policy forms,
long-term care benefit classifications are defined as
follows: institutional long-term care benefits only, non-institutional
long-term care benefits only, or comprehensive long-term care benefits.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
amd by #10782, eff 2-13-15; ss by #13400, eff 6-22-22
Ins 3601.04 Policy Definitions. No
long-term care insurance policy delivered or issued for delivery in this state
shall use the terms set forth below, unless the terms are defined in the policy
and the definitions satisfy the following requirements:
(a) “Activities of daily living”
means at least bathing, continence, dressing, eating, toileting, and transferring;
(b) “Acute condition” means that the
individual is medically unstable. Such an individual requires
frequent monitoring by medical professionals, such as physicians and registered
nurses, in order to maintain his or her health status;
(c) “Adult
day care” means a program for 6 or more individuals of social and
health-related services provided during the day in a community group setting for
the purpose of supporting frail, impaired elderly, or other disabled adults who
can benefit from care in a group setting outside the home;
(d) “Bathing” means washing oneself
by sponge bath or in either a tub or shower, including the task of getting into
or out of the tub or shower;
(e) “Cognitive impairment” means a
deficiency in a person's short or long-term memory, orientation as to person,
place, and time, deductive or abstract reasoning, or judgment as it relates to
safety awareness;
(f) “Continence” means the ability
to maintain control of bowel or bladder function or, when unable to maintain
control of bowel or bladder function, the ability to perform associated
personal hygiene (including caring for catheter or colostomy bag);
(g) “Dressing” means putting on and
taking off all items of clothing and any necessary braces, fasteners, or
artificial limbs;
(h) “Eating” means feeding oneself
by getting food into the body from a receptacle (such as a plate, cup, or
table) or by a feeding tube or intravenously;
(i) “Hands-on
assistance” means physical assistance (minimal, moderate, or maximal) without
which the individual would not be able to perform the activity of daily living;
(j) “Home health care services”
means medical and nonmedical services provided to ill, disabled, or infirm
persons in their residences. Such services may include homemaker
services, assistance with activities of daily living, and respite care services;
(k) “Medicare” means “The Health
Insurance for the Aged Act, Title XVIII of the Social Security Amendments of
1965 as Then Constituted or Later Amended” or “Title I, Part I of Public Law
89-97, as Enacted by the Eighty-Ninth Congress of the United States of America
and popularly known as the Health Insurance for the Aged Act, as then
constituted and any later amendments or substitutes thereof”, or words of
similar import;
(l) “Mental or nervous disorder”
shall not be defined to include more than neurosis, psychoneurosis,
psychopathy, psychosis, or mental or emotional disease or disorder;
(m) “Personal care” means the
provision of hands-on services to assist an individual with activities of
daily living;
(n) “Skilled nursing care”, “personal
care”, “home care”, “specialized care”, “assisted living care”, and
other services shall be defined in relation to the level of skill required, the
nature of the care, and the setting in which care must be delivered;
(o) “Toileting” means getting to and
from the toilet, getting on and off the toilet, and performing associated
personal hygiene;
(p) “Transferring” means moving into
or out of bed, chair, or wheelchair; and
(q) All providers of services,
including but not limited to “skilled nursing facility”, “extended care
facility”, “convalescent
nursing home”, “personal care facility”, “specialized care providers”, “assisted
living facility”, and “home care agency” shall be defined in relation to the
services and facilities required to be available and the licensure,
certification, registration, or degree status of those providing or
supervising the services. When the definition requires that the
provider be appropriately licensed, certified, or registered, it
shall also state what requirements a provider must meet in lieu of licensure, certification,
or registration when the state in which the service is to be furnished does not
require a provider of these services to be licensed, certified or registered, or
when the state licenses, certifies, or registers the provider of services under
another name.
Source. #8036, eff
5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22
Ins 3601.05 Policy Practices and
Provisions.
(a) Renewability. The
terms “guaranteed renewable” and “noncancellable” shall not be used in any
individual long-term care insurance policy without further explanatory language
in accordance with the disclosure requirements of Ins 3601.08.
(1) A policy issued to an individual shall not contain
renewal provisions other than “guaranteed renewable” or “noncancellable”;
(2) The term “guaranteed renewable” may be used only when
the insured has the right to continue the long-term care insurance in force by
the timely payment of premiums and when the insurer has no unilateral right to
make any change in any provision of the policy or rider while the insurance is
in force, and cannot decline to renew, except that rates may be revised by the
insurer on a class basis;
(3) The term “noncancellable” may be used only when the
insured has the right to continue the long-term care insurance in force by the
timely payment of premiums during which period the insurer has no right to
unilaterally make any change in any provision of the insurance or in the premium
rate;
(4) The term “level premium” may only be used when the
insurer does not have the right to change the premium; and
(5) In addition to the other requirements of this paragraph,
a qualified long-term care insurance contract shall be guaranteed renewable,
within the meaning of Section 7702B(b)(1)(C) of the Internal Revenue Code of
1986, as amended.
(b) Limitations
and Exclusions. A policy may not be delivered or issued for delivery
in this state as long-term care insurance if the policy limits or excludes
coverage by type of illness, treatment, medical condition, or
accident, except as follows:
(1) Preexisting conditions or diseases;
(2) Mental or nervous disorders; however, this shall not
permit exclusion or limitation of benefits on the basis of Alzheimer's Disease;
(3) Alcoholism and drug addiction;
(4) Illness, treatment, or medical condition
arising out of:
a. War or act of war (whether declared or undeclared);
b. Participation in a felony, riot, or insurrection;
c. Service in the armed forces or units auxiliary
thereto;
d. Suicide (sane or insane), attempted suicide, or
intentionally self-inflicted injury; or
e. Aviation (this exclusion applies only to non-fare-paying
passengers);
(5) Treatment provided in a government facility (unless
otherwise required by law), services for which benefits are available under
Medicare or other governmental program (except Medicaid), any state or federal
workers’ compensation, employer’s liability, or occupational disease law, or any
motor vehicle no-fault law, services provided by a member of the covered person’s
immediate family, and services for which no charge is normally made in the
absence of insurance;
(6) Expenses for services or items available or paid under
another long-term care insurance or health insurance policy;
(7) In the case of a qualified long-term care insurance
contract, expenses for services or items to the extent that the expenses are
reimbursable under Title XVIII of the Social Security Act or would be so
reimbursable but for the application of a deductible or coinsurance amount;
(8) a. This paragraph is not intended to prohibit exclusions
and limitations by type of provider. However, no long-term care
issuer may deny a claim because services are provided in a state other than the
state of policy issued under the following conditions:
1. When the state other than the state of policy issue does
not have the provider licensing, certification, or registration required in the
policy, but where the provider satisfies the policy requirements outlined for
providers in lieu of licensure, certification, or registration; or
2. When the state other than the state of policy issue
licenses, certifies, or registers the provider under another name; and
b. For purposes of this paragraph, “state of policy issue”
means the state in which the individual policy or certificate was originally
issued; and
(9) This paragraph is not intended to prohibit territorial
limitations.
(c) Extension
of Benefits. Termination of long-term care insurance shall be
without prejudice to any benefits payable for institutionalization if the
institutionalization began while the long-term care insurance was in force and
continues without interruption after termination. The extension of
benefits beyond the period the long-term care insurance was in force may be
limited to the duration of the benefit period, if any, or to payment of the
maximum benefits and may be subject to any policy waiting period and all other
applicable provisions of the policy.
(d) Continuation
or Conversion.
(1) Group long-term care insurance issued in this state on
or after the effective date of this section shall provide covered individuals
with a basis for continuation or conversion of coverage;
(2) For the purposes of this section, “a basis for
continuation of coverage” means a policy provision that maintains coverage under
the existing group policy when the coverage would otherwise terminate and which is subject only to the continued
timely payment of premium when due. Group policies that restrict
provision of benefits and services to, or contain
incentives to use certain providers or facilities may provide continuation
benefits that are substantially equivalent to the benefits of the existing
group policy. The commissioner shall make a
determination as to the substantial equivalency of benefits and, in doing
so, shall take into consideration the differences between managed care and
non-managed care plans, including, but not limited to, provider system arrangements,
service availability, benefit levels, and administrative complexity;
(3) For the purposes of this section, “a basis for
conversion of coverage” means a policy provision that an individual whose
coverage under the group policy would otherwise terminate or has been terminated
for any reasons, including discontinuance of the group policy in its entirety
or with respect to an insured class, and who has been continuously insured
under the group policy (and any group policy which it replaced) for at least
six months immediately prior to termination, shall be entitled to the issuance
of a converted policy by the insurer under whose group policy he or she is covered,
without evidence of insurability;
(4) For the purpose of this section, “converted policy”
means an individual policy of long-term care insurance providing benefits
identical to, or benefits determined by the commissioner to be substantially
equivalent to, or in excess of those
provided under the group policy from which conversion is made. Where
the group policy from which conversion is made restricts provision of benefits
and services to, or contains incentives to use certain providers or facilities,
the commissioner, in making a determination as to the substantial
equivalency of benefits, shall take into consideration the differences between
managed care and non-managed care plans, including, but not limited to,
provider system arrangements, service availability, benefits levels, and administrative
complexity;
(5) Written application for the converted policy shall be
made and the first premium due, if any, shall be paid as directed by the insurer
not later than 31 days after termination of coverage under the group
policy. The converted policy shall be issued effective on the day following
the termination of coverage under the group policy and shall be
renewable annually;
(6) Unless the group policy from which conversion is made
replaced previous group coverage, the premium for the converted policy shall be
calculated on the basis of the insured’s age
at inception of coverage under the group policy from which conversion is
made. Where the group policy from which conversion is made replaced
previous group coverage, the premium for the converted policy shall be calculated on
the basis of the insured’s age at inception of coverage under the group
policy replaced;
(7) Continuation of coverage or issuance of a converted
policy shall be mandatory, except where:
a. Termination of group coverage resulted from an individual’s
failure to make any required payment of premium or contribution when due; or
b. The terminating coverage is replaced, not later than 31
days after termination, by group coverage effective on the day following the
termination of coverage:
1. Providing benefits identical to or benefits determined by
the commissioner to be substantially equivalent to or in
excess of those provided by the terminating coverage; and
2. The premium for which is calculated in a manner consistent
with the requirements of subparagraph (6) of this paragraph;
(8) Notwithstanding any other provision of this section, a
converted policy issued to an individual who, at the time of conversion is
covered by another long-term care insurance policy that provides benefits on
the basis of incurred expenses, may contain a provision that results in a
reduction of benefits payable if the benefits provided under the additional coverage,
together with the full benefits provided by the converted policy, would result
in payment of more than 100 percent of incurred expenses. The
provision shall only be included in the converted policy if the converted
policy also provides for a premium decrease or refund which reflects the
reduction in benefits payable;
(9) The converted policy may provide that benefits payable
under the converted policy, together with the benefits payable under the group
policy from which conversion is made, shall not exceed those that would have
been payable had the individual's coverage under the group policy remained in
force and effect;
(10) Notwithstanding any other provision of this section, an
insured individual whose eligibility for group long-term care coverage is based
upon his or her relationship to another person shall be entitled to
continuation of coverage under the group policy upon termination of the
qualifying relationship by death or dissolution of marriage; and
(11) For the purposes of this section, a “managed-care plan”
is a health care or assisted living arrangement designed to coordinate patient
care or control costs through utilization review, case management, or use of
specific provider networks.
(e) Discontinuance
and Replacement. If a group long-term care policy is replaced by
another group long-term care policy issued to the same policyholder, the
succeeding insurer shall offer coverage to all persons covered under the
previous group policy on its date of termination. Coverage provided
or offered to individuals by the insurer and premiums charged to persons under
the new group policy:
(1) Shall not result in an exclusion for preexisting
conditions that would have been covered under the group policy being replaced;
and
(2) Shall not vary or otherwise depend on the individual's
health or disability status, claim experience, or use of long-term
care services.
(f) (1) The
premium charged to an insured shall not increase due to either:
a. The increasing age of the insured at ages beyond 65; or
b. The duration the insured has been covered under the policy;
(2) The purchase of additional coverage shall not be
considered a premium rate increase, but for purposes of the calculation
required under Ins 3601.25, the portion of
the premium attributable to the additional coverage shall be added to and
considered part of the initial annual premium; and
(3) A reduction in benefits shall not be considered a
premium change, but for purpose of the calculation required under Ins 3601.25, the initial annual premium shall be based
on the reduced benefits.
(g) Electronic
Enrollment for Group Policies.
(1) In the case of a group defined in RSA 415-D:3 IV(a), any
requirement that a signature of an insured be obtained by an agent or insurer
shall be deemed satisfied if:
a. The consent is obtained by telephonic or electronic
enrollment by the group policyholder or insurer. A verification of
enrollment information shall be provided to the enrollee;
b. The telephonic or electronic enrollment provides
necessary and reasonable safeguards to assure the accuracy, retention and prompt retrieval of records; and
c. The telephonic or electronic enrollment provides
necessary and reasonable safeguards to assure that the confidentiality of
individually identifiable information as defined by Ins 3001.04(v)
is maintained; and
(2) The insurer shall make available, upon request of the
commissioner, records that will demonstrate the insurer's ability to confirm
enrollment and coverage amounts.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.06 Unintentional Lapse. Each
insurer offering long-term care insurance shall, as a protection against
unintentional lapse, comply with the following:
(a) (1) Notice before lapse or
termination. No individual long-term care policy or certificate shall
be issued until the insurer has received from the applicant either a written designation
of at least one person, in addition to the applicant, who is to receive notice
of lapse or termination of the policy or certificate for nonpayment of premium,
or a written waiver dated and signed by the applicant electing not to designate
additional persons to receive notice. The applicant has the right to
designate at least one person who is to receive the notice of termination, in
addition to the insured. Designation shall not constitute acceptance
of any liability on the third party for services provided to the
insured. The form used for the written designation shall provide
space clearly designated for listing at least one person. The designation
shall include each person's full name and home address. In
the case of an applicant who elects not to designate an additional person, the
waiver shall state: “Protection against unintended lapse. I understand that I have the right to designate
at least one person other than myself to receive notice of lapse or termination
of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given
until 30 days after a premium is due and unpaid. I elect NOT to designate
a person to receive this notice." The insurer shall notify the
insured of the right to change this written designation, no less often than
once every 2 years;
(2) When the
policyholder or certificateholder pays
premium for a long-term care insurance policy or certificate through a payroll
or pension deduction plan, the requirements contained in subparagraph (a)(1)
need not be met until 60 days after the policyholder or certificateholder is no longer on such a payment
plan. The application or enrollment form for such policies or
certificates shall clearly indicate the payment plan selected by
the applicant; and
(3) Lapse or
termination for nonpayment of premium. No individual long-term care
policy or certificate shall lapse or be terminated for nonpayment of premium
unless the insurer, at least 30 days before the effective date of the lapse or
termination, has given notice to the insured and to those persons designated
pursuant to subparagrpah (a)(1), at the address
provided by the insured for purposes of receiving notice of lapse or
termination. Notice shall be given by first class United
States mail, postage prepaid; and notice may not be given until 30 days
after a premium is due and unpaid. Notice shall be deemed to have
been given as of 5 days after the date of mailing.
(b) Reinstatement. In addition to the
requirement in paragraph (a), a long-term care insurance policy or certificate
shall include a provision that provides for reinstatement of coverage, in the
event of lapse, if the insurer is provided proof that the policyholder or certificateholder was cognitively impaired or had a
loss of functional capacity before the grace period contained in the policy
expired. This option shall be available to the insured if requested
within 5 months after termination and shall allow for the collection of past
due premium, where appropriate. The standard of proof of cognitive
impairment or loss of functional capacity shall not be more stringent than the
benefit eligibility criteria on cognitive impairment or the loss of functional
capacity contained in the policy and certificate.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.07 Required Disclosure
Provisions.
(a) Renewability. Individual
long-term care insurance policies shall contain a renewability provision:
(1) The provision
shall be appropriately captioned, shall appear on the first page of the policy,
and shall clearly state that the coverage is guaranteed renewable or
noncancellable. This provision shall not apply to policies that do
not contain a renewability provision and under which the right to nonrenew is reserved solely to the policyholder; and
(2) A long-term
care insurance policy or certificate, other than one where the insurer does not
have the right to change the premium, shall include a statement that premium
rates may change.
(b) Riders and Endorsements. Except
for riders or endorsements by which the insurer effectuates a request made in
writing by the insured under the individual long-term care insurance policy,
all riders or endorsements added to an individual long-term care insurance
policy after date of issue or at reinstatement or renewal that reduce or eliminate
benefits or coverage in the policy shall require signed acceptance by the
individual insured. After the date of policy issue, any rider or
endorsement which increases benefits or coverage with a concomitant increase in
premium during the policy term shall be agreed to in writing signed by the
insured, except if the increased benefits or coverage are required by
law. Where a separate additional premium is charged for benefits
provided in connection with riders or endorsements, the premium charge shall be
set forth in the policy, rider, or endorsement.
(c) Payment of Benefits. A
long-term care insurance policy that provides for the payment of benefits based
on standards described as “usual and customary”, “reasonable and customary”, or
words of similar import shall include a definition of these terms and an
explanation of the terms in its accompanying outline of coverage.
(d) Limitations. If a
long-term care insurance policy or certificate contains any limitations with
respect to preexisting conditions, the limitations shall appear as a separate
paragraph of the policy or certificate and shall be labeled as “Preexisting
Condition Limitations”.
(e) Other Limitations or Conditions
on Eligibility for Benefits. A long-term care insurance policy or
certificate containing any limitations or conditions for eligibility other than
those prohibited in RSA 415-D:5 IV(b), (c) and (d) shall set forth a description
of the limitations or conditions, including any required number of days of
confinement, in a separate paragraph of the policy or certificate and shall
label such paragraph “Limitations or Conditions on Eligibility for Benefits”.
(f) Disclosure of Tax
Consequences. With regard to life
insurance policies that provide an accelerated benefit for long-term care, a
disclosure statement is required at the time of application for the policy or
rider and at the time the accelerated benefit payment request is submitted that
receipt of these accelerated benefits may be taxable, and that assistance
should be sought from a personal tax advisor. The disclosure
statement shall be prominently displayed on the first page of the policy or
rider and any other related documents. This paragraph shall not
apply to qualified long-term care insurance contracts.
(g) Benefit
Triggers. Activities of daily living and cognitive impairment shall
be used to measure an insured’s need for long-term care and shall be described
in the policy or certificate in a separate paragraph and shall be labeled “Eligibility
for the Payment of Benefits”. Any additional benefit triggers shall
also be explained in this section. If these triggers differ for
different benefits, explanation of the trigger shall accompany each benefit
description. If an attending physician or other specified person
must certify a certain level of functional dependency in
order to be eligible for benefits, this too shall be specified.
(h) A qualified long-term care insurance
contract shall include a disclosure statement in the policy and in the outline
of coverage, as contained in Ins 3601.32(e)3.,
that the policy is intended to be a qualified long-term care insurance contract
under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.
(i) A
nonqualified long-term care insurance contract shall include a disclosure
statement in the policy and in the outline of coverage, as contained in Ins 3601.32(e)3., that the policy is not intended to be
a qualified long-term care insurance contract.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.08 Required Disclosure of
Rating Practices to Consumers.
(a) This section shall apply as
follows:
(1) Except as
provided in (2) below, this section applies to any long-term care policy or
certificate issued in this state on or after the effective date of this rule;
and
(2) For
certificates issued on or after the effective date of this amended rule under a
group long-term care insurance policy as defined in RSA 415-D:3 IV(a),
which policy was in force at the time this amended rule became effective, the
provisions of this section shall apply on the policy anniversary following 12
months after the effective date of this amended rule.
(b) Other than policies for which no
applicable premium rate or rate schedule increases can be made, insurers shall
provide all of the information listed in
this paragraph to the applicant at the time of application or enrollment,
unless the method of application does not allow for delivery at that
time. In such a case, an insurer shall provide all of the information listed below to the applicant no
later than at the time of delivery of the policy or certificate:
(1) A statement
that the policy may be subject to rate increases in the future;
(2) An
explanation of potential future premium rate revisions, and the policyholder’s or certificateholder’s option in the event of a premium
rate revision;
(3) The premium
rate or rate schedules applicable to the applicant that will be in effect until
a request is made for an increase;
(4) A general explanation
for applying premium rate or rate schedule adjustments that shall include:
a. A description
of when premium rate or rate schedule adjustments will be effective (e.g., next
anniversary date, next billing date, etc.); and
b. The right to a
revised premium rate or rate schedule as provided in paragraph (3) if the premium
rate or rate schedule is changed; and
(5) a. Information
regarding each premium rate increase on this policy form or similar policy forms
over the past 10 years for this state or any other state that, at a minimum,
identifies:
1. The policy
forms for which premium rates have been increased;
2. The calendar
years when the form was available for purchase; and
3. The amount or
percent of each increase. The percentage may be expressed as a percentage
of the premium rate prior to the increase, and may also be expressed
as minimum and maximum percentages if the rate increase is variable by rating characteristics;
b. The insurer
may, in a fair manner, provide additional explanatory information related to the
rate increases;
c. An insurer
shall have the right to exclude from the disclosure premium rate increases that
only apply to blocks of business acquired from other nonaffiliated insurers or the
long-term care policies acquired from other nonaffiliated insurers when those
increases occurred prior to the acquisition;
d. If an
acquiring insurer files for a rate increase on a long-term care policy form
acquired from nonaffiliated insurers or a block of policy forms acquired from
nonaffiliated insurers on or before the later of the effective date of this
section or the end of a 24 month period following
the acquisition of the block or policies, the acquiring insurer may exclude
that rate increase from the disclosure. However, the nonaffiliated
selling company shall include the disclosure of that rate increase in accordance
with clause a. of this subparagraph; and
e. If the
acquiring insurer in clause d. above files for a subsequent rate increase, even
within the 24 month period, on the same
policy form acquired from nonaffiliated insurers or block of policy forms
acquired from nonaffiliated insurers referenced in clause d., the acquiring
insurer shall make all disclosures required by this subparagraph (5), including
disclosure of the earlier rate increases referenced in clause d.
(c) An applicant shall sign an
acknowledgement at the time of application, unless the method of application
does not allow for signature at that time, that the insurer made the disclosure
required under (b)(1) and (5) above. If, due to the method of
application, the applicant cannot sign an acknowledgement at the time of
application, the applicant shall sign no later than at the time of delivery of
the policy or certificate.
(d) An insurer shall use the forms
in Appendices B and F to comply with the requirements of (b) and (c) of this
section.
(e) An
insurer shall provide notice of an upcoming premium rate schedule increase to all
policyholders or certificateholders, if
applicable, at least 45 days prior to the implementation of the premium rate
schedule increase by the insurer. The notice shall:
(1) Include the
information required by paragraph (b) when the rate increase is implemented;
(2) Include
available benefit reduction and other rate increase mitigation options; and
(3) Address the guaranteed renewable nature of the
policy so that the insured shall understand that the premium rates may increase
again in the future.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
amd by #10782, eff 2-13-152; ss by #13400, eff 6-22-22
Ins 3601.09 Initial Filing
Requirements.
(a) This section applies to any
long-term care policy issued in this state on or after the effective date of
this rule.
(b) An insurer shall provide the
information listed in this paragraph to the commissioner 30 days prior to
making a long-term care insurance form available for sale:
(1) A copy of the disclosure documents
required in Ins 3601.08; and
(2) An actuarial certification
consisting of at least the following:
a. A statement
that the initial premium rate schedule is sufficient to cover anticipated costs
under moderately adverse experience and that the premium rate schedule is
reasonably expected to be sustainable over the life of the form with no future
premium increases anticipated;
b. A statement
that the policy design and coverage provided have been reviewed and taken into consideration;
c. A statement
that the underwriting and claims adjudication processes have been reviewed and
taken into consideration;
d. A complete
description of the basis for contract reserves that are anticipated to be held under
the form, to include:
1. Sufficient
detail or sample calculations provided so as to have a complete depiction of
the reserve amounts to be held;
2. A statement
that the assumptions used for reserves contain reasonable margins for adverse experience;
3. A statement that the
net valuation premium for renewal years does not increase (except for
attained-age rating where permitted); and
4. A statement
that the difference between the gross premium and the net valuation premium for
renewal years is sufficient to cover expected renewal expenses; or if such a
statement cannot be made, a complete description of the situations where this
does not occur;
(i) An
aggregate distribution of anticipated issues may be used as long as the underlying
gross premiums maintain a reasonably consistent relationship;
(ii) If the gross
premiums for certain age groups appear to be inconsistent with this requirement,
the commissioner may request a demonstration under (c) based on a standard age
distribution; and
e. 1. A statement that the premium rate schedule is not
less than the premium rate schedule for existing similar policy forms also
available from the insurer except for reasonable differences attributable to
benefits; or
2. A comparison
of the premium schedules for similar policy forms that are currently available
from the insurer with an explanation of the differences.
(c) (1) The commissioner may request an
actuarial demonstration that benefits are reasonable in relation to premiums. The
actuarial demonstration shall include either premium and claim experience on
similar policy forms, adjusted for any premium or benefit differences, relevant
and credible data from other studies, or both; and
(2) In the event the commissioner asks for
additional information under this provision, the period in (b) above does not
include the period during which the insurer is preparing the requested information.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.10 Prohibition Against
Post-Claims Underwriting.
(a) All applications for long-term
care insurance policies or certificates, except those that are guaranteed issue,
shall contain clear and unambiguous questions designed to ascertain the health
condition of the applicant.
(b) (1) If
an application for long-term care insurance contains a question that asks whether
the applicant has had medication prescribed by a physician, it shall also ask
the applicant to list the medication that has been prescribed; and
(2) If the
medications listed in the application were known by the insurer,
or should have been known at the time of application, to be
directly related to a medical condition for which coverage would otherwise be
denied, then the policy or certificate shall not be rescinded for that condition.
(c) Except for policies or certificates
which are guaranteed issue:
(1) The following
language shall be set out conspicuously and in close conjunction with the applicant's
signature block on an application for a long-term care insurance policy or
certificate:
“Caution: If your
answers on this application are incorrect or untrue, [company] has the right to
deny benefits or rescind your policy.”;
(2) The following
language, or language substantially similar to the
following, shall be set out conspicuously on the long-term care insurance policy
or certificate at the time of delivery:
“Caution: The
issuance of this long-term care insurance [policy] [certificate] is based upon your
responses to the questions on your application. A copy of your
[application] [enrollment form] [is enclosed] [was retained by you when you
applied]. If your answers are incorrect or untrue, the company has
the right to deny benefits or rescind your policy. The best time to clear
up any questions is now, before a claim arises! If, for any reason,
any of your answers are incorrect, contact the company at this address: [insert
address]”;
(3) Prior to
issuance of a long-term care policy or certificate to an applicant age 80 or older, the insurer shall obtain one of the
following:
a. A report of a
physical examination;
b. An assessment
of functional capacity;
c. An attending
physician's statement; or
d. Copies of
medical records;
(4) A copy of the
completed application or enrollment form (whichever is applicable) shall be delivered
to the insured no later than at the time of delivery of the policy or
certificate unless it was retained by the applicant at the time of application;
and
(5) Every insurer
or other entity selling or issuing long-term care insurance benefits shall
maintain a record of all policy or certificate rescissions, both state and
countrywide, except those that the insured voluntarily effectuated and shall
annually furnish this information to the insurance commissioner in the format
prescribed by the National Association of Insurance Commissioners in Appendix
A.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.11 Minimum Standards
for Home Health and Community Care Benefits in Long-Term Care Insurance
Policies.
(a) A long-term care insurance
policy or certificate shall not, if it provides benefits for home health care
or community care services, limit or exclude benefits:
(1) By requiring that
the insured or claimant would need care in a skilled
nursing facility if home health care services were not provided;
(2) By requiring
that the insured or claimant first or simultaneously receive nursing or
therapeutic services, or both, in a home, community, or institutional setting
before home health care services are covered;
(3) By limiting
eligible services to services provided by registered nurses or licensed practical nurses;
(4) By requiring
that a nurse or therapist provide services covered by the policy that can be provided
by a home health aide, or other licensed or certified home care worker acting
within the scope of his or her licensure or certification;
(5) By excluding
coverage for personal care services provided by a home health aide;
(6) By requiring
that the provision of home health care services be at a level of certification
or licensure greater than that required by the eligible service;
(7) By requiring
that the insured or claimant have an acute condition before home health care services
are covered;
(8) By limiting
benefits to services provided by Medicare-certified agencies or providers; or
(9) By excluding
coverage for adult day care services.
(b) A long-term care insurance
policy or certificate, if it provides for home health or community care
services, shall provide total home health or community care coverage that is a
dollar amount equivalent to at least one-half of one year's coverage available
for nursing home benefits under the policy or certificate, at the time covered
home health or community care services are being received. This
requirement shall not apply to policies or certificates issued to residents of
continuing care retirement communities.
(c) Home health care coverage may
be applied to the nonhome health care benefits provided in the policy or
certificate when determining maximum coverage under the terms of the policy or
certificate.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.12 Requirement to Offer
Inflation Protection.
(a) No insurer may offer a long-term
care insurance policy unless the insurer also offers to the policyholder in
addition to any other inflation protection the option to purchase a policy that
provides for benefit levels to increase with benefit maximums or reasonable
durations which are meaningful to account for reasonably anticipated increases
in the costs of long-term care services covered by the
policy. Insurers shall offer to each policyholder, at the time of
purchase, the option to purchase a policy with an inflation protection feature
no less favorable than one of the following:
(1) Increases benefit
levels annually in a manner so that the increases are compounded annually at a
rate of not less than 5 percent;
(2) Guarantees
the insured individual the right to periodically increase benefit levels
without providing evidence of insurability or health status so long as the
option for the previous period has not been declined. The amount of
the additional benefit shall be no less than the difference between the
existing policy benefit and that benefit compounded annually at a rate of at
least 5 percent for the period beginning with the purchase of the existing
benefit and extending until the year in which the offer is made; or
(3) Covers a
specified percentage of actual or reasonable charges and does not include a
maximum specified indemnity amount or limit.
(b) Where the policy is issued to a
group, the required offer in (a) above shall be made to the group policyholder;
except, if the policy is issued to a group defined in RSA 415-D:3 IV(d)
other than to a continuing care retirement community, the offering shall be
made to each proposed certificateholder.
(c) The offer in (a) above shall not
be required of life insurance policies or riders containing accelerated long-term
care benefits.
(d) (1) Insurers
shall include the following information in or with the outline of coverage:
a. A graphic
comparison of the benefit levels of a policy that increases benefits over the policy
period with a policy that does not increase benefits. The graphic
comparison shall show benefit levels over at least a 20
year period; and
b. Any expected
premium increases or additional premiums to pay for automatic or optional benefit
increases; and
(2) An insurer
may use a reasonable hypothetical, or a graphic demonstration, for the purposes
of this disclosure.
(e) Inflation
protection benefit increases under a policy which contains these benefits shall
continue without regard to an insured's age, claim status, or claim history, or
the length of time the person has been insured under the policy.
(f) An
offer of inflation protection that provides for automatic benefit increases
shall include an offer of a premium which the insurer expects to remain
constant. The offer shall disclose in a conspicuous manner that the
premium may change in the future unless the premium is guaranteed to remain
constant.
(g) (1) Inflation protection
as provided in (a)(1) of this section shall be included in a long-term care
insurance policy unless an insurer obtains a rejection of inflation protection
signed by the policyholder as required in this paragraph. The
rejection may be either in the application or on a separate form; and
(2) The rejection
shall be considered a part of the application and shall state:
“I
have reviewed the outline of coverage and the graphs that compare the benefits
and premiums of this policy with and without inflation
protection. Specifically, I have reviewed Plans _______, and I
reject inflation protection.”
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.13 Requirements for
Application Forms and Replacement Coverage.
(a) Application
forms shall include the following questions designed to elicit information as
to whether, as of the date of the application, the applicant has another
long-term care insurance policy or certificate in force or whether a long-term
care policy or certificate is intended to replace any other accident and
sickness or long-term care policy or certificate presently in
force. A supplementary application or other form to be signed by the
applicant and producer, except where the coverage is sold without a producer,
containing the questions may be used. With regard
to a replacement policy issued to a group defined by RSA 415-D:3,
IV(a), the following questions may be modified only to the extent necessary to
elicit information about health or long-term care insurance policies other than
the group policy being replaced, provided that the certificateholder has
been notified of the replacement:
(1) Do you have
another long-term care insurance policy or certificate in force (including
health care service contract, health maintenance organization contract)?
(2) Did you have
another long-term care insurance policy or certificate in force during the last
12 months?
a. If so, with
which company?
b. If that policy
lapsed, when did it lapse?
(3) Are you covered
by Medicaid?
(4) Do you intend
to replace any of your medical or health insurance coverage with this policy (certificate)?
(b) Producers
shall list any other health insurance policies they have sold to the applicant:
(1) List policies
that are still in force; and
(2) List policies
sold in the past 5 years that are no longer in force.
(c) Solicitations Other than Direct
Response. Upon determining that a sale will involve replacement, an
insurer, other than an insurer using direct response solicitation methods, or
its producer, shall furnish the applicant, prior to issuance or delivery of the
individual long-term care insurance policy, a notice regarding replacement of
accident and sickness or long-term care coverage. One copy of the
notice shall be retained by the applicant and an additional copy signed by the
applicant shall be retained by the insurer. The required notice
shall be provided in the following manner:
“NOTICE TO APPLICANT REGARDING REPLACEMENT
OF INDIVIDUAL ACCIDENT AND SICKNESS OR
LONG-TERM CARE INSURANCE
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE
IMPORTANT TO YOU IN THE FUTURE
According to [your application] [information you have furnished],
you intend to lapse or otherwise terminate existing accident and sickness or
long-term care insurance and replace it with an individual long-term care
insurance policy to be issued by [company name] Insurance
Company. Your new policy provides 30 days within which you may
decide, without cost, whether you desire to keep the policy. For
your own information and protection, you should be aware of and seriously
consider certain factors which may affect the insurance protection available to
you under the new policy.
You should review this new coverage carefully, comparing it with
all accident and sickness or long-term care insurance coverage you now have,
and terminate your present policy only if, after due consideration, you find
that purchase of this long-term care coverage is a wise decision.
STATEMENT TO APPLICANT BY PRODUCER OR OTHER REPRESENTATIVE
(Use additional
sheets, as necessary)
I have reviewed your current medical or health insurance
coverage. I believe the replacement of insurance involved in this
transaction materially improves your position. My conclusion
has taken into account the following
considerations, which I call to your attention:
1. Health
conditions that you may presently have (preexisting conditions) may not be
immediately or fully covered under the new policy. This could result
in denial or delay in payment of benefits under the new policy, whereas a
similar claim might have been payable under your present policy.
2. State
law provides that your replacement policy or certificate may not contain new
preexisting conditions or probationary periods. The insurer will
waive any time periods applicable to preexisting conditions or probationary
periods in the new policy (or coverage) for similar benefits to the extent such
time was spent (depleted) under the original policy.
3. If
you are replacing existing long-term care insurance coverage, you may wish to
secure the advice of your present insurer or its producer regarding the
proposed replacement of your present policy. This is not only your
right, but it is also in your best interest to make sure you understand all the
relevant factors involved in replacing your present coverage.
4. If,
after due consideration, you still wish to terminate your present policy and
replace it with new coverage, be certain to truthfully
and completely answer all questions on the application concerning your
medical health history. Failure to include all material medical
information on an application may provide a basis for the company to deny any
future claims and to refund your premium as though your policy had never been
in force. After the application has been completed and before you
sign it, re-read it carefully to be certain that all information has been
properly recorded.
________________________________________________
(Signature of Producer or Other Representative)
[Typed Name and Address of Producer]
The above "Notice to Applicant" was delivered to me on:
_______________________________ _________________________”
(Applicant's Signature) (Date)
(d) Direct Response
Solicitations. Insurers using direct response solicitation methods
shall deliver a notice regarding replacement of accident and sickness or
long-term care coverage to the applicant upon issuance of the
policy. The required notice shall be provided in the following
manner:
“NOTICE TO APPLICANT REGARDING REPLACEMENT
OF ACCIDENT AND SICKNESS OR LONG-TERM CARE
INSURANCE
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE
IMPORTANT TO YOU IN THE FUTURE.
According to [your application] [information you have furnished],
you intend to lapse or otherwise terminate existing accident and sickness or
long-term care insurance and replace it with the long-term care insurance
policy delivered herewith issued by [company name] Insurance
Company. Your new policy provides 30 days within which you may
decide, without cost, whether you desire to keep the policy. For
your own information and protection, you should be aware of and seriously consider
certain factors which may affect the insurance protection available to you
under the new policy.
You should review this new coverage carefully, comparing it with
all accident and sickness or long-term care insurance coverage you now have,
and terminate your present policy only if, after due consideration, you find
that purchase of this long-term care coverage is a wise decision.
1. Health
conditions which you may presently have (preexisting conditions), may not be
immediately or fully covered under the new policy. This could result
in denial or delay in payment of benefits under the new policy, whereas a
similar claim might have been payable under your present policy.
2. State
law provides that your replacement policy or certificate may not contain new
preexisting conditions or probationary periods. Your insurer will
waive any time periods applicable to preexisting conditions or probationary
periods in the new policy (or coverage) for similar benefits to the extent such
time was spent (depleted) under the original policy.
3. If
you are replacing existing long-term care insurance coverage, you may wish to
secure the advice of your present insurer or its producer regarding the
proposed replacement of your present policy. This is not only your
right, but it is also in your best interest to make sure you understand all the
relevant factors involved in replacing your present coverage.
4. [To
be included only if the application is attached to the policy.] If,
after due consideration, you still wish to terminate your present policy and
replace it with new coverage, read the copy of the application attached to your
new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements
in the application could cause an otherwise valid claim to be denied. Carefully
check the application and write to [company name and address] within 30 days if
any information is not correct and complete, or if any past medical history has
been left out of the application.”
(e) Where replacement is intended, the replacing
insurer shall notify, in writing, the existing insurer of the proposed
replacement. The existing policy shall be identified by the insurer, name of
the insured and policy number or address including zip code. Notice shall be
made within 5 working days from the date the application is received by the
insurer or the date the policy is issued, whichever is sooner.
(f) Life insurance policies that accelerate benefits
for long-term care shall comply with this section if the policy being replaced
is a long-term care insurance policy. If the policy being replaced is a life
insurance policy, the insurer shall comply with the replacement requirements of
Ins 302. If a life insurance policy that accelerates
benefits for long-term care is replaced by another such policy, the replacing
insurer shall comply with both the long-term care and the life insurance
replacement requirements.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.14 Reporting Requirements.
(a) Every insurer shall maintain
records for each producer of that producer’s amount of replacement sales as a
percent of the producer’s total annual sales and the amount of
lapses of long-term care insurance policies sold by the producer as a percent of
the producer’s total annual sales.
(b) Every insurer shall report
annually by June 30 the 10 percent of its producers with the greatest
percentages of lapses and replacements as measured by (a) above. (See Appendix
G)
(c) Reported replacement and lapse
rates do not alone constitute a violation of insurance laws or necessarily
imply wrongdoing. The reports are for the purpose of reviewing more
closely producer activities regarding the sale of long-term care insurance.
(d) Every insurer shall report
annually by June 30 the number of lapsed policies as a percent of its total
annual sales and as a percent of its total number of policies in force as of
the end of the preceding calendar year. (See Appendix G)
(e) Every insurer shall report
annually by June 30 the number of replacement policies sold as a percent of its
total annual sales and as a percent of its total number of policies in force as
of the preceding calendar year. (See Appendix G)
(f) Every insurer shall report
annually by June 30, for qualified long-term care insurance contracts, the
number of claims denied for each class of business, expressed as a percentage
of claims denied. (See Appendix E)
(g) For purposes of this section:
(1) “Policy”
means only long-term care insurance;
(2) Subject to
paragraph (3), “claim” means a request for payment of benefits under an in force policy regardless of whether the benefit
claimed is covered under the policy or any terms or conditions of the policy
have been met;
(3) “Denied”
means the insurer refuses to pay a claim for any reason other than for claims
not paid for failure to meet the waiting period or because of an applicable
preexisting condition; and
(4) “Report”
means on a statewide basis.
(h) Reports required under this
section shall be filed with the commissioner.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.15 Licensing. A
producer is not authorized to sell, solicit, or negotiate with respect to long
term care insurance except
as authorized by RSA 402-J.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.16 Discretionary Powers
of Commissioner. The commissioner may, upon written request and
after an administrative hearing, issue an order to modify or suspend a specific
provision or provisions of this rule with respect to a specific long-term care
insurance policy or certificate upon a written finding that:
(a) The modification or suspension
would be in the best interest of the insureds;
(b) The purposes to be achieved
could not be effectively or efficiently achieved without the modification or
suspension; and
(c) (1) The
modification or suspension is necessary to the development of an innovative and
reasonable approach for insuring long-term care; or
(2) The policy or
certificate is to be issued to residents of a life care or continuing care
retirement community or some other residential community for the elderly and
the modification or suspension is reasonably related to the special needs or
nature of such a community; or
(3) The
modification or suspension is necessary to permit long-term care insurance to
be sold as part of, or in conjunction with, another insurance product.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.17 Reserve Standards.
(a) (1) When
long-term care benefits are provided through the acceleration of benefits under
group or individual life policies or riders to such policies, policy reserves for
the benefits shall be determined in accordance with RSA 410. Claim
reserves shall also be established in the case when the policy or rider is in
claim status; and
(2) Reserves for policies
and riders subject to this paragraph should be based on the multiple decrement
model utilizing all relevant decrements except for voluntary termination
rates. Single decrement approximations are acceptable if the
calculation produces essentially similar reserves, if the reserve is clearly
more conservative, or if the reserve is immaterial. The calculations
may take into account the reduction in life
insurance benefits due to the payment of long-term care
benefits. However, in no event shall the reserves for the long-term
care benefit and the life insurance benefit be less than the reserves for the
life insurance benefit assuming no long-term care benefit;
(3) In the
development and calculation of reserves for policies and riders subject to this
paragraph, due regard shall be given to the applicable policy provisions, marketing
methods, administrative procedures and all other considerations which have an
impact on projected claim costs, including, but not limited to, the following:
a. Definition of
insured events;
b. Covered
long-term care facilities;
c. Existence of
home convalescence care coverage;
d. Definition
of facilities;
e. Existence or
absence of barriers to eligibility;
f. Premium
waiver provision;
g. Renewability;
h. Ability to
raise premiums;
i. Marketing method;
j. Underwriting procedures;
k. Claims adjustment procedures;
l. Waiting period;
m. Maximum benefit;
n. Availability
of eligible facilities;
o. Margins in
claim costs;
p. Optional
nature of benefit;
q. Delay in
eligibility for benefit;
r. Inflation protection
provisions; and
s. Guaranteed
insurability option; and
(4) Any
applicable valuation morbidity table shall be certified as appropriate as a
statutory valuation table by a member of the American Academy of
Actuaries.
(b) When long-term care benefits are
provided other than as in (a) above, reserves shall be determined in accordance
with RSA 410.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.18 Loss Ratio.
(a) This
section shall apply to all long-term care insurance policies or certificates
except those covered under Ins 3601.09 and
Ins 3601.19.
(b) Benefits
under long-term care insurance policies shall be deemed reasonable in relation
to premiums provided the expected loss ratio is at least 60 percent calculated
in a manner which provides for adequate reserving of the long-term care
insurance risk. In evaluating the expected loss ratio, due
consideration shall be given to all relevant factors, including:
(1) Statistical
credibility of incurred claims experience and earned premiums;
(2) The period
for which rates are computed to provide coverage;
(3) Experienced and
projected trends;
(4) Concentration
of experience within early policy duration;
(5) Expected
claim fluctuation;
(6) Experience
refunds, adjustments or dividends;
(7) Renewability features;
(8) All
appropriate expense factors;
(9) Interest;
(10) Experimental
nature of the coverage;
(11) Policy reserves;
(12) Mix of
business by risk classification; and
(13) Product
features such as long elimination periods, high deductibles, and high
maximum limits.
(c) Paragraph
(b) above shall not apply to life insurance policies that accelerate benefits
for long-term care. A life insurance policy that funds long-term
care benefits entirely by accelerating the death benefit is considered to
provide reasonable benefits in relation to premiums paid, if the policy
complies with all of the following
provisions:
(1) The interest
credited internally to determine cash value accumulations, including long-term care,
if any, are guaranteed not to be less than the minimum guaranteed interest rate
for cash value accumulations without long-term care set forth in the policy;
(2) The portion
of the policy that provides life insurance benefits meets the nonforfeiture requirements of RSA 409;
(3) The policy
meets the disclosure requirements of RSA 415-D:8, VI, VII, and VIII;
(4) Any policy
illustration that meets the applicable requirements of Ins 309;
and
(5) An actuarial
memorandum is filed with the insurance department that includes:
a. A description
of the basis on which the long-term care rates were determined;
b. A description
of the basis for the reserves;
c. A summary of
the type of policy, benefits, renewability, general marketing method, and limits
on ages of issuance;
d. A description
and a table of each actuarial assumption used. For expenses, an
insurer shall include percent of premium dollars per policy and dollars per
unit of benefits, if any;
e. A description
and a table of the anticipated policy reserves and additional reserves to be held
in each future year for active lives;
f. The estimated
average annual premium per policy and the average issue age;
g. A statement as to whether underwriting is performed at
the time of application. The statement shall indicate whether
underwriting is used and, if used, the statement shall include a description of
the type or types of underwriting used, such as medical underwriting or functional
assessment underwriting. Concerning a group policy, the statement
shall indicate whether the enrollee or any dependent will be underwritten and
when underwriting occurs; and
h. A description
of the effect of the long-term care policy provision on the required premiums, nonforfeiture
values, and reserves on the underlying life insurance policy, both for active
lives and those in long-term care claim status.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.19 Premium Rate
Schedule Increases.
(a) This
section shall apply to all requests for premium rate schedule increases.
(b) An
insurer shall provide notice of a pending premium rate schedule increase,
including an exceptional increase, to the commissioner at least 30 days prior
to the notice to the policyholders and shall include:
(1) Information
required by Ins 3601.08;
(2) Certification
by a qualified actuary that:
a. If the requested
premium rate schedule increase is implemented and the underlying assumptions
are realized, then no further premium rate schedule increases are anticipated;
b. The premium
rate filing is in compliance with the provisions of this section;
(3) An actuarial memorandum justifying
the rate schedule change request that includes:
a. Lifetime projections of earned premiums and incurred
claims based on the filed premium rate schedule increase; and the method and
assumptions used in determining the projected values, including reflection of
any assumptions that deviate from those used for pricing other forms currently
available for sale;
1. Annual values
for the 5 years preceding the 3 years following the valuation date shall be provided separately;
2. The
projections shall include the development of the lifetime loss ratio;
3. The
projections shall demonstrate compliance with paragraph (c) below; and
4. For
exceptional increases:
(i) The
projected experience should be limited to the increases in claims expenses attributable
to the approved reasons for the exceptional increase; and
(ii) In the event
the commissioner determines, as provided in Ins 3601.03(b)(4);
that offsets may exist, the insurer shall use appropriate net projected experience;
b. Disclosure of how reserves have been incorporated in
this rate increase whenever the rate increase will trigger contingent benefit
upon lapse;
c. Disclosure of the analysis performed to determine why
a rate adjustment is necessary, which pricing assumptions were not realized and
why, and what other actions taken by the company have been relied on by the actuary;
d. A statement that policy design, underwriting, and
claims adjudication practices have been taken into consideration; and
e. In the event that it is necessary to maintain consistent
premium rates for new certificates and certificates receiving a rate increase,
the insurer will need to file composite rates reflecting projections of
new certificates;
(4) A statement
that renewal premium rate schedules are not greater than new business premium rate
schedules except for differences attributable to benefits, unless sufficient
justification is provided to the commissioner;
(5) Sufficient
information for review and approval of the premium rate schedule increase by
the commissioner; and
(6) In assessing
the reasonableness of the assumptions proposed, the commissioner may use the services
of an independent actuary and may charge the insurer for the cost of these
services. The commissioner may also accept a review done by or for
another state or states for the same or substantially the same policy form
where any differences in benefits and premiums are not material and such review
was completed within 18 months of the date of the premium rate schedule filing and
substantially complies with these standards.
(c) All
premium rate schedule increases shall be determined in accordance with the
following requirements:
(1) Exceptional
increases shall provide that 70 percent of the present value of projected
additional premiums from the exceptional increase will be returned to policyholders
in benefits;
(2) Premium rate
schedule increases shall be calculated such that the sum of the accumulated value
of incurred claims, without the inclusion of active life reserves, and the
present value of future projected incurred claims, without the inclusion of
active life reserves, will not be less than the sum of the following:
a. For
policies issued on or after May 1, 2004:
1. The
accumulated value of the initial earned premium times the difference between 2 percent
and the greater of the original anticipated loss ratio when the product was originally
filed and 60 percent;
2. Eighty-five
percent of the accumulated value of prior premium rate schedule increases on an
earned basis;
3. The present value
of future projected initial earned premiums times the difference between 2
percent and the greater of the original anticipated loss ratio when the product
was originally filed and 60 percent; and
4. Eighty-five
percent of the present value of future projected premiums not in sub-clause 3. above
on an earned basis; and
b. For policies
issued prior to May 1, 2004:
1. The
accumulated value of earned premium, using rates that
had been approved and implemented prior to January 1,
2016, times the difference between 2 percent and the greater of the original
anticipated loss ratio when the product was originally filed and 62 percent;
2. Eighty percent
for individual policies and 75 percent for group policies of the accumulated
value of premium rate increases approved and proposed for implementation on or
after January 1, 2016;
3. The present
value of future projected earned premium using rates that had been approved and
implemented prior to January 1, 2016, times the difference between 2 percent
and the greater of the original anticipated loss ratio when the product was originally
filed and 62 percent; and
4. Eighty percent
for individual policies and 75 percent for group policies of the present value
of future projected premiums not in sub-clause 3. above on an earned basis;
(3) In the event
that a policy form has both exceptional and other increases, the values in sub-clauses
(c)(2)a.2. and 4. above will also include 70 percent for exceptional rate
increase amounts;
(4) All present and
accumulated values used to determine rate increases shall use the maximum valuation
interest rate for contract reserves. The actuary shall disclose as
part of the actuarial memorandum the use of any appropriate averages;
(5) All
calculated accumulated values shall use the actual experience of the product,
except for the interest rate as specified in subparagraph (4) above, in as close a
manner to that used in the original development of rates as
possible. This shall not preclude the inclusion of multiple policy forms
into one rate increase determination if such pooling enhances the credibility
of the combined accumulated experience; and
(6) All calculated
present values shall use reasonable estimates of future premium payments and claim
payments. Such estimates shall be based on reasonable assumptions,
which may include a margin for moderately adverse experience, as characterized
herein.
(d) For
any increase that is greater than 20 percent, the insurer shall be required to
implement a series of scheduled increases to ensure that no policyholder will
realize an annual rate increase of more than 20%. The entire
scheduled series, or methodology for establishing a series, shall be approved
as part of the rate filing justifying the premium rate schedule
increase. For the purposes of Ins 3601.08(e),
any schedule series implemented pursuant to this paragraph shall be considered
one premium rate schedule increase. The insurer shall
not be permitted to implement any further increases on the subject policy
during the period of such scheduled increases. The insurer shall not
be permitted to implement any further increases within the period during which
scheduled increases previously approved are being implemented.
(e) For
each rate increase that is implemented, the insurer shall file for review by
the commissioner updated projections, as defined in (b)(3)a. above, every 2
years during the period over which scheduled increases are being implemented
and include a comparison of actual results to projected values. For group insurance policies that meet the
conditions in paragraph (l) below, the projections required by this paragraph shall
be provided to the policyholder in lieu of filing with the commissioner.
(f) If
any premium rate in the revised premium rate schedule is greater than 200
percent of the comparable rate in the initial premium schedule, lifetime
projections, as defined in paragraph (b)(3)a. above, shall be filed for
review by the commissioner every 5 years following the end of the required period
in paragraph (e) above. For group insurance policies that meet the
conditions in paragraph (l) below, the projections required by this paragraph shall
be provided to the policyholder in lieu of filing with the commissioner.
(g) (1) If the commissioner has
determined that the actual experience following a rate increase does not
adequately match the projected experience and that the current
projections demonstrate that incurred claims will not exceed
proportions of premiums specified in paragraph (c), the commissioner may
require the insurer to implement any of the following:
a. Premium rate
schedule adjustments; or
b. Other measures
to reduce the difference between the projected and actual experience; and
(2) In
determining whether the actual experience adequately matches the projected
experience, consideration should be given to clause (b)(3)e. above, if applicable.
(h) If the majority of the policies or certificates to which
the increase is applicable are eligible for the contingent benefit upon lapse,
the insurer shall file:
(1) A plan,
subject to commissioner approval, for improved administration or claims processing
designed to eliminate the potential for further deterioration of the policy
form requiring further premium rate schedule increases, or both, or to
demonstrate that appropriate administration and claims processing have been
implemented or are in effect; otherwise the
commissioner may impose the condition in paragraph (i)
of this section; and
(2) The original anticipated
lifetime loss ratio, and the premium rate schedule increase that would have
been calculated according to paragraph (c) had the greater of the original
anticipated lifetime loss ratio or 58 percent been used in the calculations
described in sub-clauses (c)(2)a.1. and 3. above.
(i) (1) For a rate increase filing
that meets the following criteria, the commissioner shall review, for all
policies included in the filing, the projected lapse rates and past lapse rates
during the 12 months following each increase to determine if significant
adverse lapsation has occurred or is anticipated:
a. The rate increase is not the first
rate increase requested for the specific policy form or forms;
b. The rate increase is not an exceptional increase; and
c. The majority of the
policies or certificates to which the increase is applicable are eligible for
the contingent benefit upon lapse; and
(2) In the event
significant adverse lapsation has occurred, is anticipated in the filing, or
is evidenced in the actual results as presented in the updated projections
provided by the insurer following the requested rate increase, the commissioner
may determine that a rate spiral exists. Following the determination
that a rate spiral exists, the commissioner may require the insurer to offer,
without underwriting, to all in force insureds subject to the rate increase the
option to replace existing coverage with one or more reasonably comparable
products being offered by the insurer or its affiliates.
a. The offer shall:
1. Be subject to
the approval of the commissioner;
2. Be based on
actuarially sound principles, but not be based on attained age; and
3. Provide that
maximum benefits under any new policy accepted by an insured shall be reduced
by comparable benefits already paid under the existing policy; and
b. The insurer shall maintain the experience of all the replacement
insureds separate from the experience of insureds originally issued the policy forms. In
the event of a request for a rate increase on the policy form, the rate
increase shall be limited to the lesser of:
1. The maximum
rate increase determined based on the combined experience; and
2. The maximum
rate increase determined based only on the experience of the insureds originally
issued the form plus 10 percent.
(j) If
the commissioner determines that the insurer has exhibited a persistent practice
of filing inadequate initial premium rates for long-term care insurance, the commissioner
may, in addition to the provisions of paragraph (i)
of this section, prohibit the insurer from either of the following:
(1) Filing and
marketing comparable coverage for a period of up to 5 years; or
(2) Offering all other
similar coverages and limiting marketing of new applications to the products subject
to recent premium rate schedule increases.
(k) Paragraphs
(a) through (j) shall not apply to policies for which the long-term care
benefits provided by the policy are incidental, as defined in Ins 3601.03(c), if the policy complies with all of the
following provisions:
(1) The interest
credited internally to determine cash value accumulations, including long-term care,
if any, rate guaranteed not to be less than the minimum guaranteed interest
rate for cash value accumulations without long-term care set forth in the policy;
(2) The portion
of the policy that provides insurance benefits other than long-term care
coverage meets the nonforfeiture requirements as applicable in any of the
following:
a. RSA 409; and
b. RSA 409-A;
(3) The policy
meets the disclosure requirements of RSA 415-D:8, VI, VII, and VIII;
(4) The portion
of the policy that provides insurance benefits other than long-term care
coverage meets the requirements as applicable in policy illustrations as
required by Ins 309;
(5) An actuarial
memorandum is filed with the insurance department that includes:
a. A description
of the basis on which the long-term care rates were determined;
b. A description
of the basis for the reserves;
c. A summary of
the type of policy, benefits, renewability, general marketing method, and limits
on ages of issuance;
d. A description
and a table of each actuarial assumption used. For expenses, an
insurer shall include percent of premium dollars per policy and dollars per
unit of benefits, if any;
e. A description
and a table of the anticipated policy reserves and additional reserves to be held
in each future year for active lives;
f. The estimated
average annual premium policy and the average issue age;
g. A statement as
to whether underwriting is performed at the time of application. The
statement shall indicate whether underwriting is used and, if used, the
statement shall include a description of the type or types of underwriting used,
such as medical underwriting or functional assessment
underwriting. Concerning a group policy, the statement shall indicate
whether the enrollee or any dependent will be underwritten and when underwriting
occurs; and
h. A description
of the effect of the long-term care policy provision on the required premiums, nonforfeiture
values and reserves on the underlying insurance policy, both for active lives
and those in long-term care status.
(l) Paragraphs
(g) and (i) shall not apply to group insurance
policies as defined in RSA 415-D:3, IV(a) where:
(1) The policies
insure 250 or more persons and the policyholder
has 5,000 or more eligible employees of a single employer; or
(2) The
policyholder, and not the certificateholders,
pays a material portion of the premium, which shall not be less than 20 percent
of the total premium for the group in the calendar year prior to the year a
rate increase is filed.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #10782, eff 2-13-15; amd by #12651, eff
10-29-18; ss by #13400, eff 6-22-22
Ins 3601.20 Filing Requirement. Prior
to an insurer or similar organization offering group long-term care insurance
to a resident of this state pursuant to RSA 415-D:4, it shall file with the
commissioner evidence that the group policy or certificate thereunder has been
approved by a state having statutory or regulatory long-term care insurance
requirements substantially similar to those
adopted in this state.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.21 Filing Requirements for
Advertising.
(a) Every
insurer, health care service plan or other entity providing long-term care
insurance or benefits in this state shall provide a copy of any long-term care
insurance advertisement intended for use in this state whether through written,
radio or television medium to the commissioner for review or approval by the
commissioner. In addition, all advertisements shall be retained by
the insurer, health care service plan or other entity for at least 3 years from
the date the advertisement was first used.
(b) The
commissioner may exempt from these requirements any advertising form or
material when, in the commissioner's opinion, this requirement may not be
reasonably applied.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
amd by #12595, eff 7-30-18; ss by #13400, eff 6-22-22
Ins 3601.22 Standards for Marketing.
(a) Every
insurer, health care service plan or other entity marketing long-term care
insurance coverage in this state, directly or through its producers, shall:
(1) Establish marketing
procedures and producer training requirements to assure that:
a. Any marketing activities, including any comparison
policies, by its producers or other producers will be fair and accurate; and
b. Excessive insurance is not sold or issued;
(2) Display
prominently by type, stamp or other
appropriate means, on the first page of the outline of coverage and policy the
following:
“Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by
the buyer during the period of coverage. The buyer is advised
to review carefully all policy limitations.”;
(3) Provide
copies of the disclosure forms required in Ins 3601.08
(Appendices B and F) to the applicant;
(4) Inquire and
otherwise make every reasonable effort to identify whether a prospective
applicant or enrollee for long-term care insurance already has accident and
sickness or long-term care insurance and the types and amounts of any such
insurance, except that in the case of qualified long-term care insurance contracts,
an inquiry into whether a prospective applicant or enrollee for long-term care insurance has accident and sickness insurance is not required;
(5) Every insurer
or entity marketing long-term care insurance shall establish auditable
procedures for verifying compliance with this paragraph;
(6) If the state in
which the policy or certificate is to be delivered or issued for delivery has a
senior insurance counseling program approved by the commissioner, the insurer
shall, at solicitation, provide written notice to the prospective policyholder
and certificateholder that the program is available
and the name, address and telephone number of the program;
(7) For long-term
care health insurance policies and certificates, use the terms “noncancellable”
or “level premium” only when the policy or certificate conforms to Ins 3601.05(a)(3) and (4); and
(8) Provide an
explanation of contingent benefit upon lapse provided for in Ins 3601.27(d)(3) and, if applicable, the additional
contingent benefit upon lapse provided to policies with fixed or limited
premium paying periods in Ins 3601.27(d)(4).
(b) In
addition to the practices prohibited in RSA 417, the following acts and
practices are prohibited:
(1) Twisting. Knowingly
making any misleading representation or incomplete or fraudulent comparison of any
insurance policies or insurers for the purpose of inducing, or tending to
induce, any person to lapse, forfeit, surrender, terminate, retain, pledge,
assign, borrow on or convert any insurance policy or to take out a policy of
insurance with another insurer;
(2) High pressure
tactics. Employing any method of marketing having the effect of or
tending to induce the purchase of insurance through force, fright, threat, whether
explicit or implied, or undue pressure to purchase or recommend the purchase of
insurance;
(3) Cold lead
advertising. Making use directly or indirectly of any method of
marketing which fails to disclose in a conspicuous manner that a purpose of the
method of marketing is solicitation of insurance and that contact will be made
by an insurance producer or insurance company; and
(4) Misrepresentation. Misrepresenting
a material fact in selling or offering to sell a long-term care insurance
policy.
(c) (1) With respect to the obligations
set forth in this paragraph, the primary responsibility of an association, as
defined in RSA 415-D:3, IV(b), when endorsing or selling long-term care
insurance shall be to educate its members concerning long-term care issues in
general so that its members can make informed decisions. Associations
shall provide objective information regarding long-term care insurance policies
or certificates endorsed or sold by such associations to ensure that members of
such associations receive a balanced and complete explanation of the features
in the policies or certificates that are being endorsed or sold;
(2) The insurer
shall file with the department the following material:
a. The policy and certificate;
b. A corresponding outline of coverage; and
c. All advertisements requested by the department;
(3) The association
shall disclose in any long-term care insurance solicitation:
a. The specific
nature and amount of the compensation arrangements (including all fees, commissions,
administrative fees and other forms of
financial support) that the association receives from endorsement or sale of the
policy or certificate to its members; and
b. A brief
description of the process under which the policies and the insurer issuing the
policies were selected;
(4) If the
association and the insurer have interlocking directorates or trustee arrangements,
the association shall disclose that fact to its members;
(5) The board of
directors of associations selling or endorsing long-term care insurance
policies or certificates shall review and approve the insurance policies as well
as the compensation arrangements made with the insurer;
(6) The
association shall also:
a. At the time of the association's decision to endorse,
engage the services of a person with expertise in long-term care insurance not
affiliated with the insurer to conduct an examination of the policies,
including its benefits, features, and rates and update the examination
thereafter in the event of material change;
b. Actively monitor the marketing efforts of the insurer
and its producers;
c. Review and approve all marketing materials or other
insurance communications used to promote sales or sent to members regarding the
policies or certificates; and
d. Subparagraphs a. through c. shall not apply to
qualified long-term care insurance contracts;
(7) No group
long-term care insurance policy or certificate may be issued to an association
unless the insurer files with the state insurance department the information
required in this section;
(8) The insurer
shall not issue a long-term care policy or certificate to an association or
continue to market such a policy or certificate unless the insurer certifies
annually that the association has complied with the requirements set forth in
this paragraph; and
(9) Failure to
comply with the filing and certification requirements of this section
constitutes an unfair trade practice in violation of RSA 417.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.23 Suitability.
(a) This
section shall not apply to life insurance policies that accelerate benefits for
long-term care.
(b) Every
insurer, health care service plan, or other entity marketing long-term care
insurance (the “issuer”) shall:
(1) Develop and
use suitability standards to determine whether the purchase or replacement of long-term
care insurance is appropriate for the needs of the applicant;
(2) Train its
producers in the use of its suitability standards; and
(3) Maintain a
copy of its suitability standards and make them available for inspection upon
request by the commissioner.
(c) (1) To determine whether the
applicant meets the standards developed by the issuer, the producer and issuer
shall develop procedures that take the following into consideration:
a. The ability to
pay for the proposed coverage and other pertinent financial information related
to the purchase of the coverage;
b. The applicant's
goals or needs with respect to long-term care and the advantages and disadvantages
of insurance to meet these goals or needs; and
c. The
values, benefits and costs of the applicant's existing insurance, if
any, when compared to the values, benefits and costs of the recommended
purchase or replacement;
(2) The issuer
and, where a producer is involved, the producer shall
make reasonable efforts to obtain the information set out in subparagraph (1)
above. The efforts shall include presentation to the applicant, at
or prior to application, the “Long-Term Care Insurance Personal Worksheet”. The
personal worksheet used by the issuer shall contain, at a minimum, the
information in the format contained in Appendix B, in not less than 12 point type. The issuer may request the
applicant to provide additional information to comply with its suitability
standards. A copy of the issuer's personal worksheet shall be filed
with the commissioner;
(3) A completed
personal worksheet shall be returned to the issuer prior to the issuer's consideration
of the applicant for coverage, except the personal worksheet need not be
returned for sales of employer group long-term care insurance to employees and
their spouses; and
(4) The sale or
dissemination outside the company or agency by the issuer or producer of information
obtained through the personal worksheet in Appendix B is prohibited.
(d) The
issuer shall use the suitability standards it has developed pursuant to this
section in determining whether issuing long-term care insurance coverage to an
applicant is appropriate.
(e) Producers
shall use the suitability standards developed by the issuer in marketing
long-term care insurance.
(f) At
the same time as the personal worksheet is provided to the applicant, the
disclosure form entitled “Things You Should Know Before You Buy Long-Term Care
Insurance” shall be provided. The form shall be in the format contained
in Appendix C, in not less than 12 point type.
(g) If
the issuer determines that the applicant does not meet its financial
suitability standards, or if the applicant has declined to provide the
information, the issuer may reject the application. In the
alternative, the issuer shall send the applicant a letter similar to Appendix D. However, if the
applicant had declined to provide financial information, the issuer may use
some other method to verify the applicant's intent. Either the applicant's
returned letter or a record of the alternative method of verification shall be
made part of the applicant's file.
(h) The
issuer shall report annually to the commissioner the total number of
applications received from residents of this state, the number of those who
declined to provide information on the personal worksheet, the number of
applicants who did not meet the suitability standards, and the number of those
who chose to confirm after receiving a suitability letter.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12; ss by #13400, eff 6-22-22
Ins 3601.24 Prohibition Against
Preexisting Conditions and Probationary Periods in Replacement Policies or
Certificates. If a long-term care insurance policy or
certificate replaces another long-term care policy or certificate, the replacing
insurer shall waive any time periods applicable to preexisting conditions and
probationary periods in the new long-term care policy for similar benefits to
the extent that similar exclusions have been satisfied under the original
policy.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.25 Availability of New
Services or Providers.
(a) An insurer
shall notify policyholders of the availability of a new long-term policy series
that provides coverage for new long-term care services or providers material in
nature and not previously available through the insurer to the general public. The notice shall be provided
within 12 months of the date of the new policy series is made available for
sale in this state.
(b) Notwithstanding
paragraph (a) above, notification is not required for any policy issued prior
to the effective date of this section or to any policyholder or certificateholder who is currently eligible for
benefits, within an elimination period or on a claim, or who previously had
been in claim status, or who would not be eligible to apply for coverage due to
issue age limitations under the new policy. The insurer may require
that policyholders meet all eligibility requirements, including underwriting
and payment of the required premium to add such new services or providers.
(c) The insurer
shall make the new coverage available in one of the following ways:
(1) By adding a
rider to the existing policy and charging a separate premium for the new rider based
on the insured's attained age;
(2) By exchanging
the existing policy or certificate for one with an issue age based on the
present age of the insured and recognizing past insured status by granting
premium credits toward the premiums for the new policy or
certificate. The premium credits shall be based on premiums paid or
reserves held for the prior policy or certificate;
(3) By exchanging
the existing policy or certificate for a new policy or certificate in which consideration
for past insured status shall be recognized by setting the premium for the new
policy or certificate at the issue age of the policy or certificate being
exchanged. The cost for the new policy or certificate may recognize
the difference in reserves between the new policy or certificate and the
original policy or certificate; or
(4) By an alternative
program developed by the insurer that meets the intent of this section if the program
is filed with and approved by the commissioner.
(d) An insurer is
not required to notify policyholders of a new proprietary policy series created
and filed for use in a limited distribution channel. For purpose of
this paragraph, "limited distribution channel" means through a
discrete entity, such as a financial institution or brokerage, for which
specialized products are available that are not available for sale to the general public. Policyholders that purchased such
a new proprietary policy shall be notified when a new long-term care policy
series that provides coverage for new long-term care services or providers
material in nature is made available to that limited distribution channel.
(e) Policies
issued pursuant to this section shall be considered exchanges and not replacements. These
exchanges shall not be subject to Ins 3601.13
and Ins 3601.23 and the reporting requirements of Ins 3601.14(a) to (e).
(f) Where
the policy is offered through an employer, labor organization, professional,
trade or occupational association, the required notification in paragraph (a)
above shall be made to the offering entity. However, if the policy
is issued to a group defined in RSA 415-D:3, IV, the notification shall be made
to each certificateholder.
(g) Nothing in
this section shall prohibit an insurer from offering any policy, rider, certificate or coverage change to any policyholder
or certificateholder. However, upon
request any policyholder may apply for currently available coverage that
includes the new services or providers. The insurer may require that
policyholders meet all eligibility requirements, including underwriting and
payment of the required premium to add such new services or providers.
(h) This
section does not apply to life insurance policies or riders containing
accelerated long-term care benefits.
(i) This section shall become effective on or
after the effective date of this amended rule.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.26 Right to
Reduce Coverage and Lower Premiums.
(a) (1) Every
long-term care insurance policy and certificate shall include a provision that
allows the policyholder or certificateholder to
reduce coverage and lower the policy or certificate premium in at least one of
the following ways:
a. Reducing the maximum benefit; or
b. Reducing the daily, weekly or
monthly benefit amount; and
(2) The insurer
may also offer other reduction options that are consistent with the policy or certificate
design or the carrier's administrative processes.
(b) The provision
shall include a description of the ways in which coverage may be reduced and
the process for requesting and implementing a reduction in coverage.
(c) The
age to determine the premium for the reduced coverage shall be based on the age
used to determine the premium for the coverage currently in force.
(d) The
insurer may limit any reduction in coverage to plans or options available for that
policy form and to those for which benefits will be available after
consideration of claims paid or payable.
(e) If a policy
or certificate is about to lapse, the insurer shall provide a written reminder
to the policyholder or certificateholder of
his or her right to reduce coverage and premiums in the notice required
by Ins 3601.06(a)(3).
(f) This
section does not apply to life insurance policies or riders containing accelerated
long-term care benefits.
(g) The
requirements of paragraphs (a) through (f) above shall apply to any long-term
care policy issued in this state on or after the adoption of this amended rule.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12;
ss by #13400, eff 6-22-22
Ins 3601.27 Nonforfeiture Benefit
Requirement.
(a) This
section does not apply to life insurance policies or riders containing
accelerated long-term care benefits.
(b) To
comply with the requirement to offer a nonforfeiture benefit pursuant to the
provisions of RSA 415-D:10:
(1) A policy or
certificate offered with nonforfeiture benefits shall have coverage elements, eligibility,
benefit triggers and benefit length that are the same as coverage to be issued
without nonforfeiture benefits. The nonforfeiture benefit included
in the offer shall be the benefit described in paragraph (e) below; and
(2) The offer
shall be in writing if the nonforfeiture benefit is not otherwise described in the
outline of coverage or other materials given to the prospective policyholder.
(c) If
the offer required to be made under RSA 415-D:10 is rejected, the insurer shall
provide the contingent benefit upon lapse described in this
section. Even if this offer is accepted for a policy with a fixed or
limited premium paying period, the contingent benefit on lapse in paragraph (d)(4)
below shall still apply.
(d) (1) After rejection of the offer
required under RSA 415-D:10, for individual and group policies without
nonforfeiture benefits, the insurer shall provide a contingent benefit upon lapse;
(2) In the event
a group policyholder elects to make the nonforfeiture benefit an option to the certificateholder, a certificate shall provide either the
nonforfeiture benefit or the contingent benefit upon lapse;
(3) A contingent
benefit on lapse shall be triggered every time an insurer increases the premium
rates to a level which results in a cumulative increase of the annual premium
equal to or exceeding the percentage of the insured's initial annual premium
set forth below based on the insured's issue age, and the policy or certificate
lapses within 120 days of the due date of the premium so increased. Unless
otherwise required, policyholders shall be notified at least 30 days prior to
the due date of the premium reflecting the rate increase:
Triggers for a Substantial
Premium Increase
|
Issue Age |
Percent Increase Over Initial Premium |
|
|
|
|
29 and under |
200% |
|
30-34 |
190% |
|
35-39 |
170% |
|
40-44 |
150% |
|
45-49 |
130% |
|
50-54 |
110% |
|
55-59 |
90% |
|
60 |
70% |
|
61 |
66% |
|
62 |
62% |
|
63 |
58% |
|
64 |
54% |
|
65 |
50% |
|
66 |
48% |
|
67 |
46% |
|
68 |
44% |
|
69 |
42% |
|
70 |
40% |
|
71 |
38% |
|
72 |
36% |
|
73 |
34% |
|
74 |
32% |
|
75 |
30% |
|
76 |
28% |
|
77 |
26% |
|
78 |
24% |
|
79 |
22% |
|
80 |
20% |
|
81 |
19% |
|
82 |
18% |
|
83 |
17% |
|
84 |
16% |
|
85 |
15% |
|
86 |
14% |
|
87 |
13% |
|
88 |
12% |
|
89 |
11% |
|
90 and over |
10% |
(4) A contingent
benefit on lapse shall also be triggered for policies with a fixed or limited premium
paying period every time an insurer increases the premium rates to a level that
results in a cumulative increase of the annual premium equal to or exceeding
the percentage of the insured's initial annual premium set forth below based on
the insured's issue age, the policy or certificate lapses within 120 days of
the due date of the premium so increased, and the ratio in Ins 3601.27(d)(6)b.
is 40 percent or more. Unless otherwise required, policyholders
shall be notified at least 30 days prior to the due date of the premium
reflecting the rate increase:
Triggers for a Substantial
Premium Increase
|
Issue Age |
Percent Increase Over Initial Premium |
|
|
|
|
Under 65 |
50% |
|
65-80 |
30% |
|
Over 80 |
10% |
|
|
|
This provision shall be in
addition to the contingent benefit provided by subparagraph (3) above and where
both are triggered, the benefit provided shall be at the option of the insured;
(5) Notwithstanding
the requirements delineated above, a contingent nonforfeiture benefit on lapse
shall also be triggered every time an insurer increases premium rates in the
policyholder’s 21st duration or later.
(6) On or before
the effective date of a substantial premium increase as defined in subparagraph
(3) above, the insurer shall:
a. Offer to reduce policy benefits provided by the
current coverage without the requirement of additional underwriting so that required
premium payments are not increased;
b. Offer to convert
the coverage to a paid-up status with a shortened benefit period in accordance
with the terms of paragraph (e) below. This option
may be elected at any time during the 120-day period referenced in subparagraph
(d)(3) above; and
c. Notify the policyholder
or certificateholder that a default or
lapse at any time during the 120-day period referenced in subparagraph (d)(3)
shall be deemed to be the election of the offer to convert in paragraph (b)
above, unless the automatic option in clause (7)c. below applies; and
(7) On or before
the effective date of a substantial premium increase as defined in subparagraph
(4) or (5) above, the insurer shall:
a. Offer to
reduce policy benefits provided by the current coverage without the requirement
of additional underwriting so that required premium payments are not increased;
b. Offer to
convert the coverage to a paid-up status where the amount payable for each
benefit is 90 percent of the amount payable in effect immediately prior to
lapse times the ratio of the number of completed months of paid premiums
divided by the number of months in the premium paying period. This
option may be elected at any time during the 120-day period referenced in subparagraph
(4) above; and
c. Notify the
policyholder or certificateholder that a
default or lapse at any time during the 120-day period referenced in subparagraph
(4) above shall be deemed to be the election of the
offer to convert in clause
b. above if the ratio is 40 percent or more;
(e) Benefits
continued as nonforfeiture benefits, including contingent benefits upon lapse,
in accordance with subparagraph (d)(3) but not subparagraph (d)(4), are
described in this paragraph:
(1) For purposes
of this paragraph, attained age rating is defined as a schedule of premiums
starting from the issue date which increases age at least one percent per year
prior to age 50, and at least 3 percent per year beyond age 50;
(2) For purposes
of this paragraph, the nonforfeiture benefit shall be of a shortened benefit period providing paid-up long-term
care insurance coverage after lapse. The same benefits (amounts and
frequency in effect at the time of lapse but not increased thereafter) will be
payable for a qualifying claim, but the lifetime maximum dollars or days of benefits
shall be determined as specified in subparagraph (3) below;
(3) The standard
nonforfeiture credit will be equal to 100 percent of the sum of all premiums
paid, including the premiums paid prior to any changes in
benefits. The insurer may offer additional shortened benefit period
options, as long as the benefits for each
duration equal or exceed the standard nonforfeiture credit for that
duration. However, the minimum nonforfeiture credit shall not be
less than 30 times the daily nursing home benefit at the time of
lapse. In either event, the calculation of the nonforfeiture credit
is subject to the limitation of paragraph (f);
(4) a. The nonforfeiture benefit shall
begin not later than the end of the third year following the policy
or certificate issue date. The contingent benefit upon lapse shall
be effective during the first 3 years as well as thereafter.
b. Notwithstanding clause a. above, for a policy or
certificate with attained age rating, the nonforfeiture benefit shall begin on
the earlier of:
1. The end of the
tenth year following the policy or certificate issue date; or
2. The end of the
second year following the date the policy or certificate is no longer subject
to attained age rating; and
(5) Nonforfeiture
credits may be used for all care and services qualifying for benefits under the
terms of the policy or certificate, up to the limits specified in the policy or
certificate.
(f) All
benefits paid by the insurer while the policy or certificate is in premium paying
status and in the paid up status will not
exceed the maximum benefits that would be payable if the policy or certificate
had remained in premium paying status.
(g) There
shall be no difference in the minimum nonforfeiture benefits as required under
this section for group and individual policies.
(h) Premiums
charged for a policy or certificate containing nonforfeiture benefits or a
contingent benefit on lapse shall be subject to the loss ratio requirements of Ins 3601.18 or Ins 3601.19, whichever is applicable,
treating the policy as a whole.
(i) To determine whether contingent nonforfeiture
upon lapse provisions are triggered under (d)(3) or (d)(4) above, a replacing
insurer that purchased or otherwise assumed a block or blocks of long-term care
insurance policies from another insurer shall calculate the percentage increase
based on the initial annual premium paid by the insured when the policy was
first purchased from the original insurer.
(j) A
nonforfeiture benefit for qualified long-term care insurance contracts that are
level premium contracts shall be offered that meets the following requirements:
(1) The
nonforfeiture provision shall be appropriately captioned;
(2) The nonforfeiture
provision shall provide a benefit available in the event of a default in the payment
of any premiums and shall state that the amount of the benefit may be
adjusted subsequent to being initially
granted only as necessary to reflect changes in claims, persistency, and
interest as reflected in changes in rates for premium paying contracts approved
by the commissioner for the same contract form; and
(3) The
nonforfeiture provision shall provide at least one of the following:
a. Reduced paid-up insurance;
b. Extended term insurance;
c. Shortened
benefit period; or
d. Other similar
offerings approved by the commissioner.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12
(from Ins 3601.25); amd by
#10782, eff 2-13-15; ss by #13400, eff 6-22-22
Ins 3601.28 Standards for
Benefit Triggers.
(a) A
long-term care insurance policy shall condition the payment of benefits on a
determination of the insured's ability to perform activities of daily living
and on cognitive impairment. Eligibility for the payment of benefits
shall not be more restrictive than requiring either a deficiency in the ability
to perform not more than 3 of the activities of daily living or the presence of
cognitive impairment.
(b) (1) Activities
of daily living shall include at least the following as defined in Ins 3601.04 and in the policy;
a. Bathing;
b. Continence;
c. Dressing;
d. Eating;
e. Toileting; and
f. Transferring;
and
(2) Insurers may
use activities of daily living to trigger covered benefits in addition to those
contained in (b)(1) above as long as they
are defined in the policy.
(c) An
insurer may use additional provisions for the determination of when benefits
are payable under a policy or certificate; however the
provisions shall not restrict, and are not in lieu of, the requirements
contained in (a) and (b) above.
(d) For
purposes of this section the determination of a deficiency shall not be more
restrictive than:
(1) Requiring the
hands-on assistance of another person to perform the prescribed activities of daily
living; or
(2) If the deficiency
is due to the presence of a cognitive impairment, supervision or verbal cueing by
another person is needed in order to protect
the insured or others.
(e) Assessments
of activities of daily living and cognitive impairment shall be performed by
licensed or certified professionals, such as physicians, nurses or social workers.
(f) Long-term
care insurance policies shall include a clear description of the process for
appealing and resolving benefit determinations.
(g) The
requirements set forth in this section shall be applicable 12 months after the effective
date of this rule and shall apply as follows:
(1) Except as
provided in (2) below, the provisions of this section apply to a long-term care
policy issued in this state on or after the effective date of this amended rule;
and
(2) For
certificates issued on or after the effective date of this section, under a group
long-term care insurance policy, as defined in RSA 415-D:3, IV(a), that was in
force at the time this amended rule became effective, the provisions of this
section shall not apply.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12
(from Ins 3601.26); ss by #13400, eff 6-22-22
Ins 3601.29 Additional Standards
for Benefit Triggers for Qualified Long-Term Care Insurance Contracts.
(a) For
purposes of this section the following definitions apply:
(1) "Qualified
long-term care services" means services that meet the requirements of
Section 7702B(c)(1) of the Internal Revenue Code of 1986, as amended, as
follows: necessary diagnostic, preventive, therapeutic, curative,
treatment, mitigation and rehabilitative services, and maintenance or personal
care services which are required by a chronically ill individual,
and are provided pursuant to a plan
of care prescribed by a licensed health care practitioner;
(2) a. "Chronically ill individual"
has the meaning prescribed for this term by Section 7702B(c)(2) of the Internal
Revenue Code of 1986, as amended. Under this provision, a chronically
ill individual means any individual who has been certified by a licensed health
care practitioner as:
1. Being unable
to perform (without substantial assistance from another individual) at least 2
activities of daily living for a period of at least 90 days due to a loss of
functional capacity; or
2. Requiring
substantial supervision to protect the individual from threats to health and safety
due to severe cognitive impairment; and
b. The term “chronically
ill individual” shall not include an individual otherwise meeting these
requirements unless within the preceding 12 month period
a licensed health care practitioner has certified that the individual meets
these requirements;
(3) “Licensed
health care practitioner” means a physician, as defined in Section 1861 (r)(1)
of the Social Security Act, a registered professional nurse, licensed
social worker, or other individual who meets requirements prescribed by
the Secretary of the Treasury; and
(4) “Maintenance
or personal care services” means any care the primary purpose of which is the provision
of needed assistance with any of the disabilities as a
result of which the individual is a chronically ill individual
(including the protection from threats to health and safety due to severe cognitive
impairment).
(b) A
qualified long-term care insurance contract shall pay only for qualified
long-term care services received by a chronically ill individual provided
pursuant to a plan of care prescribed by a licensed health care practitioner.
(c) A
qualified long-term care insurance contract shall condition the payment of
benefits on a determination of the insured's inability to perform activities of
daily living for an expected period of at least 90 days due to a loss of
functional capacity or to severe cognitive impairment.
(d) Certifications
regarding activities of daily living and cognitive impairment required pursuant
to paragraph (c) above shall be performed by the following
licensed or certified professionals: physicians, registered
professional nurses, licensed social workers, or other individuals who meet
requirements prescribed by the Secretary of the Treasury.
(e) Certifications
required pursuant to paragraph (c) above may be performed by a
licensed health care professional at the direction of the carrier as is
reasonably necessary with respect to a specific claim, except that when a
licensed health care practitioner has certified that an insured is
unable to perform activities of daily living for an expected period of at least
90 days due to a loss of functional capacity and the insured is in claim
status, the certification may not be rescinded and additional certifications
may not be performed until after the expiration of the 90 day period.
(f) Qualified
long-term care insurance contracts shall include a clear description of the process
of appealing and resolving disputes with respect to benefit determinations.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12
(from Ins 3601.27); ss by #13400, eff 6-22-22
Ins 3601.30 Appealing an Insurer’s
Determination That the Benefit Trigger Is Not Met.
(a) For purposes
of this section, "authorized representative" is authorized to act as
the covered person's personal representative within the meaning of 45 CFR 164.502(g)
promulgated by the Secretary under the Administrative Simplification provisions
of the Health Insurance Portability and Accountability Act and means the
following:
(1) A person to
whom a covered person has given express written consent to represent the
covered person in an external review;
(2) A person authorized
by law to provide substituted consent for a covered person; or
(3) A family
member of the covered person or the covered person's treating health care
professional only when the covered person is unable to provide consent.
(b) If an insurer
determines that the benefit trigger of a long-term care insurance policy has
not been met, it shall provide a clear, written notice to the insured and the
insured's authorized representative, if applicable, of all
of the following:
(1) The reason
that the insurer determined that the insured's benefit trigger has not
been met;
(2) The insured's
right to internal appeal in accordance with paragraph (c), and the right to
submit new or additional information relating to the benefit trigger denial with
the appeal request; and
(3) The insured's
right, after exhaustion of the insurer's internal appeal process to have the
benefit trigger determination reviewed under the independent review process in
accordance with paragraph (d) below.
(c) Internal Appeal. The
insured or the insured’s authorized representative may appeal the insurer's
adverse benefit trigger determination by sending a written request to the
insurer, along with any additional supporting information, within 120 calendar days
after the insured and the insured’s authorized representative, if applicable,
receives the insurer’s benefit determination notice. The internal
appeal shall be considered by an individual or group of individuals designated
by the insurer, provided that the individual or individuals making the internal
appeal decision may not be the same individual or individuals who made the
initial benefit determination. The internal appeal shall be completed and written notice of the internal appeal
decision shall be sent to the insured and the insured's authorized representative,
if applicable, within 30 calendar days of the insurer's receipt of all
necessary information upon which a final determination can be made, and:
(1) If the
insurer's original determination is upheld upon internal appeal, the notice of
the internal appeal decision shall describe any additional internal appeal
rights offered by the insurer. Nothing herein shall require the
insurer to offer any internal appeal rights other than those described in this paragraph;
(2) If the insurer's
original determination is upheld after the internal appeal process has been
exhausted, and new or additional information has not been provided to the
insurer, the insurer shall provide a written description of the insured's right
to request an independent review of the benefit determination as described in paragraph (d)
below
to the insured and the insured's authorized representative, if applicable;
(3) As part of
the written description of the insured's right to request an independent
review, an insurer shall include the following, or substantially equivalent,
language:
“We have determined that the
benefit eligibility criteria (“benefit trigger”) of your [policy][certificate]
has not been met. You may have the right to an independent review of
our decision conducted by long-term care professionals who are not associated
with us. Please send a written request for independent review to us
at [address]. You must inform us, in writing, of your election to
have this decision reviewed within 120 days of receipt of this
letter. Listed below are the names and contact information of the
independent review organizations approved or certified by your state insurance
commissioner's office to conduct long-term care insurance benefit eligibility reviews. If
you wish to request an independent review, please choose one of the listed organizations
and include its name with your request for independent review. If
you elect independent review, but do not choose an independent review
organization with your request, we will choose one for the independent review
organizations for you and refer the request for independent review to it.”;
(4) If the
insurer does not believe the benefit trigger decision is eligible for independent
review, the insurer shall inform the insured and the insured's authorized
representative, if applicable, and the commissioner in writing and include in
the notice the reasons for its determination of independent review ineligibility;
and
(5) The appeal
process described in this paragraph is not deemed to be a “new service or
provider” as referenced in Ins 3601.25, and
therefore does not trigger the notice requirements of that section.
(d) Independent
Review of Benefit Trigger Determination:
(1) Request. The
insured or the insured’s authorized representative may request an independent
review of the insurer’s benefit trigger determination after the internal appeal
process outlined in paragraph (c) above has been exhausted. A
written request for independent review may be made by the insured or the
insured’s authorized representative to the insurer within 120 calendar days
after the insurer’s written notice of the final internal appeal decision is
received by the insured and the insured's authorized representative, if applicable;
(2) Cost. The
cost of the independent review shall be borne by the insurer; and
(3) Independent
Review Process:
a. Within 5
business days of receiving a written request for independent review, the
insurer shall refer the request to the independent review organization that the
insured or the insured's authorized representative has chosen from the list of
certified or approved organizations the insurer has provided to the
insured. If the insured or the insured's authorized representative
does not choose an approved independent review organization to perform the
review, the insurer shall choose an independent review organization approved or
certified by the state. The insurer shall vary its selection of
authorized independent review organizations on a rotating basis;
b. The insurer
shall refer the request for independent review of a benefit trigger
determination to an independent review organization, subject to the following:
1. The
independent review organization shall be on a list of certified or approved
independent review organizations that satisfy the requirements of a qualified
long-term care insurance independent review organization contained in
this section;
2. The independent
review organization shall not have any conflicts of interest with the insured,
the insured's authorized representative, if applicable, or the insurer; and
3. Such review
shall be limited to the information or documentation provided to and considered
by the insurer in making its determination, including any information or
documentation considered as part of the internal appeal process;
c. If the insured
or the insured's authorized representative has new or additional information
not previously provided to the insurer, whether submitted to the insurer or the
independent review organization, such information shall first be considered in
the internal review process, as set forth in paragraph (c) above, and:
1. While this
information is being reviewed by the insurer, the independent review
organization shall suspend its review, and the time period for review
is suspended until the insurer completes its review;
2. The insurer
shall complete its review of the information and provide written notice of the
results of the review to the insured and the insured's authorized representative,
if applicable, and the independent review organization within 5 business days
of the insurer's receipt of such new or additional information; and
3. If the insurer
maintains its denial after such review, the independent review organization
shall continue its review and render its decision within the time period specified in clause i.
below. If the insurer overturns its decision following its review,
the independent review request shall be considered withdrawn;
d. The insurer
shall acknowledge in writing to the insured and the insured’s authorized
representative, if applicable, and the commissioner that the request for
independent review has been received, accepted, and forwarded to an
independent review organization for review. Such notice will include
the name and address of the independent review organization;
e. Within 5
business days of receipt of the request for independent review, the independent
review organization assigned pursuant to this paragraph shall notify the
insured and the insured’s authorized representative, if applicable, the insurer,
and the commissioner that it has accepted the independent review request and
identify the type of licensed health care professional assigned to the
review. The assigned independent review organization shall include
in the notice a statement that the insured or the insured's authorized
representative may submit in writing to the independent review organization
within 7 days following the date of receipt of the notice additional information
and supporting documentation that the independent review organization should
consider when conducting its review;
f. The
independent review organization shall review all of the
information and documents received pursuant to clause e. above that has been
provided to the independent review organization. The independent
review organization shall provide copies of any documentation or
information provided by the insured or the insured's authorized representative
to the insurer for its review, if it is not part of
the information or documentation submitted by the insurer to the independent
review organization. The insurer shall review the information and
provide its analysis of the new information in accordance with clause h. below;
g. The insured or
the insured’s authorized representative may submit, at any time, new or
additional information not previously provided to the insurer but pertinent to
the benefit trigger denial. The insurer shall consider such
information and affirm or overturn its benefit trigger
determination. If the insurer affirms its benefit trigger
determination, the insurer shall promptly provide such new or additional
information to the independent review organization for its review, along with
the insurer’s analysis of such information;
h. If the insurer
overturns its benefit trigger determination:
1. The insurer
shall provide notice to the independent review organization and the insured and
the insured’s authorized representative, if applicable, and the commissioner of
its decision; and
2. The
independent review process shall immediately cease;
i. The independent
review organization shall provide the insured and the insured’s authorized
representative, if applicable, the insurer, and the commissioner with written
notice of its decision, within 30 calendar days from receipt of the referral
referenced in clause b. above. If the independent review
organization overturns the insurer’s decision, it shall:
1. Establish the precise
date within the specific period of time under review that the benefit trigger
was deemed to have been met;
2. Specify the
specific period of time under review for
which the insurer declined eligibility but during which the independent review
organization deemed the benefit trigger to have been met; and
3. For
tax-qualified long-term care insurance contracts, provide a certification (made
only by a licensed health care practitioner as defined in section 7702B(c)(4)
of the Internal Revenue Code) that the insured is a chronically ill individual;
j. The decision
of the independent review organization with respect to whether the insured met
the benefit trigger will be final and binding on the insurer;
k. The
independent review organization’s determination shall be used solely to establish
liability for benefit trigger decisions and is intended to be
admissible in any proceeding only to the extent it establishes the eligibility
of benefits payable;
l. Nothing in
this section shall restrict the insured's right to submit a new request for benefit
trigger determination after the independent review decision, should the
independent review organization uphold the insurer’s decision;
m. The insurance
department shall utilize the criteria set forth in Appendix H, Guidelines for
Long-Term Care Independent Review Entities, in certifying or approving entities
to review long-term care insurance benefit trigger decisions; and
n. The
commissioner shall maintain and periodically update a list of approved independent
review organizations.
(e) Certification
of Long-Term Care Insurance Independent Review Organizations. The
commissioner shall certify or approve a qualified long-term care insurance
independent review organization, provided the independent review organization
demonstrates to the satisfaction of the commissioner that it is unbiased and
meets the following qualifications:
(1) Have on
staff, or contract with, a qualified and licensed health care professional in an
appropriate field for determining an insured’s functional or cognitive
impairment (e.g., physical therapy, occupational therapy, neurology,
physical medicine, and rehabilitation) to conduct the review;
(2) Neither it
nor any of its licensed health care professionals may, in any manner, be
related to or affiliated with an entity that previously provided medical care
to the insured;
(3) Utilize a
licensed health care professional who is not an employee of the insurer or
related in any manner to the insured;
(4) Neither it nor
its licensed health care professional who conducts the reviews may receive compensation
of any type that is dependent on the outcome of the review;
(5) Be state approved
or certified to conduct such reviews, if the state requires such approvals or certifications;
(6) Provide a
description of the fees to be charged by it for independent reviews of a
long-term care insurance benefit trigger decision. Such fees shall
be reasonable and customary for the type of long-term care insurance benefit
trigger decision under review;
(7) Provide the
name of the medical director or health care professional responsible for the
supervision and oversight of the independent review procedure; and
(8) Have on staff
or contract with a licensed health care practitioner, as defined by section
7702B(c)(4) of the Internal Revenue Code of 1986, as amended, who is qualified
to certify that an individual is chronically ill for purposes of a qualified
long-term care insurance contract.
(f) Maintenance
of Records and Reporting Obligations by Independent Review
Organizations. Each certified independent review organization shall
comply with the following:
(1) Maintain
written documentation establishing the date it receives a request for independent
review, the date each review is conducted, the resolution, the date such
resolution was communicated to the insurer and the insured, and the
name and professional status of the reviewer conducting such review in an
easily accessible and retrievable format for the year in which it received the
information, plus 2 calendar years;
(2) Be able to
document measures taken to appropriately safeguard the confidentiality of such
records and prevent unauthorized use and disclosures in accordance with applicable
federal and state law;
(3) Report
annually to the commissioner, by June 1, in the aggregate and for each
long-term care insurer of all of the
following:
a. The total
number of requests received for independent review of long-term care benefit trigger decisions;
b. The total number
of reviews conducted and the resolution of such reviews (i.e., the number of
reviews which upheld or overturned the long-term care insurer’s determination
that the benefit trigger was not met);
c. The number of
reviews withdrawn prior to review;
d. The percentage
of reviews conducted within the prescribed timeframe set forth in clause (d)(3)i. above; and
(4) Report
immediately to the commissioner any change in its status which would cause it
to cease meeting any of the qualifications required of an independent review organization
performing independent reviews of long-term care benefit trigger decisions.
(g) Additional
Rights. Nothing contained in this section shall limit the ability of
an insurer to assert any rights an insurer may have under the policy related to:
(1) An insured’s misrepresentation;
(2) Changes in
the insured’s benefit eligibility; and
(3) Terms,
conditions, and exclusions of the policy, other than failure to meet the benefit
trigger.
(h) Applicability. The
requirements of this rule apply to a benefit trigger request made on or after
the adoption of this rule under a long-term care insurance policy.
(i) Conflict with Other Laws. RSA
420-J:5-a, RSA 420-J:5-b; RSA 420-J:5-c, and Ins 2703
shall not be
applicable for the purposes of external review requirements for long term care
insurance.
Source. #8036, eff 5-1-04; ss by #10154, eff 6-25-12
(from Ins 3601.27); ss by #13400, eff 6-22-22
Ins 3601.31 Prompt Payment
of Clean Claims.
(a) For purposes
of this section:
(1) “Claim” means
a request for payment of benefits under an in-force policy, regardless of
whether the benefit claimed is covered under the policy or any terms or
conditions of the policy have been met; and
(2) “Clean claim”
means a claim that has no defect or impropriety, including any lack of required
substantiating documentation, such as satisfactory evidence of expenses
incurred, or particular circumstance requiring
special treatment that prevents timely payment from being made on the claim.
(b) Within
30 business days after receipt of a claim for benefits under a long-term care
insurance policy or certificate, the insurer shall pay such claim, if it is a
clean claim, or send a written notice acknowledging the date of receipt of the
claim and one of the following:
(1) The insurer
is declining to pay all or part of the claim and the specific reason(s) for
denial; or
(2) That
additional information is necessary to determine if all or any part of the
claim is payable and the specific additional information that is necessary.
(c) Within
30 business days after receipt of all the requested additional information, an
insurer shall pay a claim for benefits under a long-term care insurance policy
or certificate if it is a clean claim, or send
a written notice that the insurer is declining to pay all or part of the claim,
and the specific reason or reasons for denial.
(d) If
an insurer fails to comply with paragraph (b) or (c) above, such insurer shall
pay interest at the rate of one percent per month on the amount of the claim
that should have been paid but that remains unpaid 45 business days after the
receipt of the claim with respect to paragraph (b) or all requested additional
information with respect to paragraph (c). The interest payable
pursuant to this paragraph shall be included in any late reimbursement without requiring
the person who filed the original claim to make any additional claim for such
interest.
(e) The
provisions of Ins 3601.31 shall not apply
where the insurer has a reasonable basis supported by specific information that
such claim was fraudulently submitted.
(f) Any
violation of this rule by an insurer, if committed flagrantly and in conscious
disregard of the provisions of this rule or with such frequency as to
constitute a general business practice, shall be considered a violation of RSA
417.
(g) The
provisions of Ins 3601.31 supersede any
other claim payment requirement found in RSA 415:6-h, RSA 415:18-k, RSA
420-A:17-d, and RSA 420-J:8-a.
Source. #10154, eff 6-25-12; ss
by #13400, eff 6-22-22
(a) The
outline of coverage shall be a free-standing document, using no smaller
than 10 point type.
(b) The
outline of coverage shall contain no material of an advertising nature.
(c) Text
that is capitalized or underscored in the standard format outline of coverage
may be emphasized by other means that provide prominence equivalent to the
capitalization or underscoring.
(d) Use
of the text and sequence of text of the standard format outline of coverage is
mandatory, unless otherwise specifically indicated.
(e) Format
for outline of coverage:
[COMPANY NAME]
[ADDRESS – CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and
Certificate Number]
[Except for policies or certificates which
are guaranteed issue, the following caution statement, or language
substantially similar, shall appear as follows in the outline of coverage.]
Caution: The issuance of this
long-term care insurance [policy] [certificate] is based upon your responses to
the questions on your application. A copy of your [application]
[enrollment form] [is enclosed] [was retained by you when you
applied]. If your answers are incorrect or untrue, the company has
the right to deny benefits or rescind your policy. The best time to
clear up any questions is now, before a claim arises! If, for any
reason, any of your answers are incorrect, contact the company at this address: [insert
address]
1. This policy is [an
individual policy of insurance] ([a group policy] which was issued in the
[indicate jurisdiction in which group policy was issued]).
2. PURPOSE OF OUTLINE OF
COVERAGE. This outline of coverage provides a very brief description
of the important features of the policy. You should compare this
outline of coverage to outlines of coverage for other policies available to
you. This is not an insurance contract, but only a summary of
coverage. Only the individual or group policy contains governing
contractual provisions. This means that the policy or group policy
sets forth in detail the rights and obligations of both you and the insurance
company. Therefore, if you purchase this coverage, or any other
coverage, it is important that you READ YOUR POLICY (OR CERTIFICATE) CAREFULLY!
3. FEDERAL TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to
be a federally tax-qualified long-term care insurance contract under Section
7702B(b) of the Internal Revenue Code of 1986, as amended.
OR
Federal Tax implications of this [POLICY]
[CERTIFICATE]. This [POLICY] [CERTIFICATE] is not intended to be a
federally tax-qualified long-term care insurance contract under Section
7702B(b) of the Internal Revenue Code of 1986, as amended. Benefits
received under the [POLICY] [CERTIFICATE] may be taxable as income.
4. TERMS UNDER WHICH THE POLICY
OR CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(a) [For long-term care health
insurance policies or certificates describe one of the following permissible
policy renewability provisions:
(1) Policies and certificates
that are guaranteed renewable shall contain the following statement:] RENEWABILITY: THIS
POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE. This means you have
the right, subject to the terms of your policy, [certificate] to continue this
policy as long as you pay your premiums on
time. [Company Name] cannot change any of the terms of your policy
on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Policies and certificates
that are noncancellable shall contain the following
statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS NONCANCELLABLE. This
means that you have the right, subject to the terms of your policy, to continue
this policy as long as you pay your premiums
on time. [Company Name] cannot change any of the terms of your
policy on its own and cannot change the premium you currently
pay. However, if your policy contains an inflation protection feature
where you choose to increase your benefits, [Company Name] may increase your
premium at that time for those additional benefits.
(b) [For group coverage,
specifically describe continuation/conversion provisions applicable to the
certificate and group policy;]
(c) [Describe waiver of premium
provisions or state that there are not such provisions.]
5. TERMS UNDER WHICH THE
COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the maximum type
required to be used for the other provisions of the outline of coverage,
state whether or not the company has a right
to change the premium, and if a right exists, describe clearly and concisely
each circumstance under which the premium may change.]
6. TERMS UNDER WHICH THE POLICY
OR CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief
description of the right to return – "free look" provision of the
policy.]
(b) [Include a statement that
the policy either does or does not contain provisions providing for a refund or
partial refund of premium upon the death of an insured or surrender of the
policy or certificate. If the policy contains such provisions,
include a description of them.]
7. THIS IS NOT MEDICARE
SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the
Medicare Supplement Buyer's Guide available from the insurance company.
(a) [For producers] Neither
[insert company name] nor its producers represent Medicare, the federal government or any state government.
(b) [For direct response]
[insert company name] is not representing Medicare, the federal government or any state government.
8. LONG-TERM CARE
COVERAGE. Policies of this category are designed to provide coverage
for one or more necessary or medically necessary diagnostic, preventive,
therapeutic, rehabilitative, maintenance, or personal care services, provided
in a setting other than an acute care unit of a hospital, such as in a nursing
home, in the community or in the home.
This policy provides coverage in the form
of a fixed dollar indemnity benefit for covered long-term care expenses, subject
to policy [limitations] [waiting periods] and [coinsurance]
requirements. [Modify this paragraph if the policy is not an
indemnity policy.]
9. BENEFITS PROVIDED BY THIS
POLICY.
(a) [Covered services, related
deductibles, waiting periods, elimination periods and benefit maximums.]
(b) [Institutional benefits, by
skill level.]
(c) [Non-institutional
benefits, by skill level.]
(d) Eligibility for Payment of
Benefits
[Activities of daily living and cognitive
impairment shall be used to measure an insured's need for long-term care and
shall be defined and described as part of the outline of coverage.]
[Any additional benefit triggers must also
be explained. If these triggers differ for different benefits,
explanation of the triggers should accompany each benefit
description. If an attending physician or other specified person
must certify a certain level of functional dependency in
order to be eligible for benefits, this too must be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Non-eligible facilities
and provider;
(c) Non-eligible levels of care
(e.g., unlicensed providers, care or treatment provided by a family member,
etc.);
(d) Exclusions and exceptions;
(e) Limitations.]
[This section should provide a brief
specific description of any policy provisions that limit, exclude, restrict,
reduce, delay, or in any other manner operate to qualify payment of the benefits
described in Number 6 above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES
ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.
11. RELATIONSHIP OF COST OF
CARE AND BENEFITS. Because the costs of long-term care services will
likely increase over time, you should consider whether and how the benefits of
this plan may be adjusted. [As applicable, indicate the following:
(a) That the benefit level will
not increase over time;
(b) Any automatic benefit
adjustment provisions;
(c) Whether the insured will be
guaranteed the option to buy additional benefits and the basis upon which
benefits will be increased over time if not by a specified amount or percentage;
(d) If there is such a guarantee,
include whether additional underwriting or health screening will be required,
the frequency and amounts of the upgrade options, and any significant
restrictions or limitations;
(e) And finally, describe
whether there will be any additional premium charge imposed, and how that is to
be calculated.]
12. ALZHEIMER’S DISEASE AND OTHER
ORGANIC BRAIN DISORDERS.
[State that the policy provides coverage
for insureds clinically diagnosed as having Alzheimer's disease or related
degenerative and dementing illnesses. Specifically describe each benefit
screen or other policy provision which provides preconditions to the
availability of policy benefits for such an insured.
13. PREMIUM.
[(a) State the total
annual premium for the policy;
(b) If the premium varies with
an applicant's choice among benefit options, indicate the portion of the annual
premium that corresponds to each benefit option.]
14. ADDITIONAL FEATURES.
[(a) Indicate if medical
underwriting is used;
(b) Describe other important
features.]
15. CONTACT THE STATE SENIOR
HEALTH INSURANCE ASSISTANCE PROGRAM IF YOU HAVE GENERAL QUESTIONS REGARDING
LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF YOU HAVE
SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE POLICY OR
CERTIFICATE.
Source. #8036, eff 5-1-04, ss by 10154, eff 6-25-12; ss
by #13400, eff 6-22-22
Ins 3601.33 Requirement to Deliver Shopper’s
Guide.
(a) A
long-term care insurance shopper’s guide in the format developed by the
National Association of Insurance Commissioners, or a guide developed or
approved by the commissioner, shall be provided to all prospective applicants
of a long-term care insurance policy or certificate.
(1) In the case
of producer solicitations, a producer shall deliver the shopper’s guide prior
to the presentation of an application or enrollment form; and
(2) In the case
of direct response solicitations, the shopper's guide shall be presented in
conjunction with any application or enrollment form.
(b) Life
insurance policies or riders containing accelerated long-term care benefits are
not required to furnish the above-referenced guide, but shall
furnish the policy summary required under RSA 415-D:8, VII.
Source. #10154, eff 6-25-12; ss
by #13400, eff 6-22-22
Ins 3601.34
Penalties. In addition to any other penalties provided by the
laws of this state, any insurer and any producer found to have violated any
requirement of this state relating to the regulation of long-term care
insurance or the marketing of such insurance shall be subject to a fine of up
to 3 times the amount of any commissions paid for each policy involved in the
violation or up to $10,000, whichever is greater.
Source. #10154, eff 6-25-12; ss
by #13400, eff 6-22-22
Ins 3601.35 Waiver
of Rules.
(a) The
commissioner, upon the commissioner’s own initiative or upon request by an
insurer, shall waive any requirement of this part if such waiver does not
contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause confusion
or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the
rule would be onerous without promoting the objective or intent of the rule provision;
or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b) No requirement
prescribed by statute shall be waived unless expressly authorized by law.
(c) Any person or
entity seeking a waiver shall make a request in writing.
(d) A request for a
waiver shall specify the basis for the waiver and proposed alternative, if any.
Source. #13400, eff 6-22-22
APPENDIX A
Rescission Reporting Form for
Long-Term Care Policies
For The State Of _____________
For The Reporting Year 20[ ]
Company Name: _______________________________________________________________
Address: _______________________________________________________________
____________________________________________________________________________
Phone Number: _______________________________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term
care insurance policies or certificates. Those rescissions
voluntarily effectuated by an insured are not required to be included in this report. Please
furnish one form per rescission.
Date
of
Date/s
Policy
Policy and Name
of Policy Claim/s Date of
Form
#
Certificate # Insured
Issuance Submitted Rescission
|
|
|
|
|
|
|
Detailed reason for rescission:________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________
Signature
_____________________________________
Name and Title (please type)
____________________________________
Date
APPENDIX B
Long-Term Care Insurance
Personal Worksheet
This worksheet will help you
understand some important information about this type of insurance. State law
requires companies issuing this [policy] [certificate] [rider] to give you some important facts about
premiums and premium increases and to ask
you some important questions to help you and the company decide if you should
buy this [policy] [certificate] [rider]. Long-term care insurance can be expensive and it may not be right for everyone.
Premium Information
The premium for the coverage you are considering
will be
[$_________ per [insert payment interval] or
a total of [$_______ per year] [a one-time single premium of $____________].
The premium quoted in this worksheet is not guaranteed and may change
during the underwriting process and in the future while this [policy]
[certificate] [rider] is in force.
Type of Policy & The Company's Right to Increase Premiums on the
Coverage You Choose:
[Noncancellable - The
company cannot increase your premiums on this [policy] [certificate] [rider]].
[Guaranteed renewable - The
company can increase your premiums on this [policy] [certificate] [rider] in
the future if it increases the premiums for all [policies] [certificates]
[riders] like yours in this state.]
[Paid-up - This [policy]
[certificate] [rider] will be paid-up after you have paid all
of the premiums specified in your [policy] [certificate] [rider]].
Premium Increase History
[Name of company] has sold long-term
care insurance since [year] and has sold this [policy] [certificate] [rider] since
[year].
[The company has never increased
its premiums for any long-term care [policy] [certificate] [rider] it has sold
in this state or any other state.]
[The company has not
increased its premiums for this [policy] [certificate] [rider] or similar
[policies] [certificates] [riders] in this state or any other state in the last
10 years.]
[The company has increased its
premiums on this [policy] [certificate] [rider] or similar [policies]
[certificates] [riders] in the last 10 years. A summary of those premium
increases follows.]
(Note: The company may
substitute the language below for the last sentence in the paragraph above and
include the full summary as an attachment to this worksheet. “Over the past 3
years, the company has increased premiums by ___%.” “A summary of premium increases
in the last 10 years is attached to this worksheet.”
Companies that have increased
premiums by 30% or more in the last ten years must include the following
statement: “There was a 30% or greater premium increase in _____[insert year].”
“A summary of premium increases in the last 10 years is attached to this
worksheet.”)
Questions About Your Income
You do not have to answer the questions that follow. They are intended to
make sure you have thought about how you’ll pay premiums and the cost of care
your insurance does not cover. If you do not want to answer these questions,
you should understand that the company might refuse to insure you.
What resources will you use to pay your premium? □Current income from
employment □Current income from investments □Other current income □Savings □Sell investments □Sell other assets □Money from my family □Other _______________
If you will be paying premiums with money received only from your own
income, a rule of thumb is that you may not be able to afford this [policy]
[certificate] [rider] if the premiums will be more than 7% of your income.
Could you afford to keep this [policy] [certificate] [rider] if your
spouse or partner dies first?
□Yes □ No □Had not thought about it □Do not know □Does not apply
What would you do if the premiums went up, for example, by 50%?
□[Pay the higher premium □Call the company/agent □Reduce benefits □Drop the [policy]
[certificate] [rider] □Do not know]
(Note: The company is not required to use the bracketed question above
if the coverage is fully paid up or is noncancellable.)
What is your household annual income from all sources? (check
one)
□[Less than $10,000] □$[10,000-19,999] □$[20,000-29,999] □$[30,000-50,000] □[More than $50,000]
Do you expect your income to change over the next 10 years? (check
one)
□No □Yes, expect increase □Yes, expect decrease
If you plan to pay premiums from your income, have you thought about
how a change in your income would affect your ability to continue to pay the
premium?
□ Yes □ No □Do not know
Will you buy inflation protection? (check one)
□ Yes □ No
Inflation may increase the cost of long-term care in the future.
If you do not buy inflation protection, how will you pay for the
difference between future costs and your daily benefit amount?
□From my income □From savings □From investments □Sell other assets □Money from my family □Other
The national average annual cost of long-term care in [insert year] was
[insert $ amount], but this figure varies across the country. In ten years the national average annual cost would be about [insert
$ amount] if costs increase 5% annually.
What [elimination period][waiting period][cash deductible] are you
considering?
[Number of days ________ in
[elimination period][waiting period]
Approximate cost of care for
this period: $_________
($xxx per day times number
of days in [elimination period] [waiting period], where “xxx” represents the
most recent estimate of the national daily average cost of long-term care)]
[Cash Deductible $________]
How do you plan to pay for your care during the [elimination period]
[waiting period] [deductible period]? (check all that apply)
□From my income □From my savings/investments □My family will pay
Questions About Your Savings and Investments
Not counting your home, about how much are all of
your assets (your savings and investments) worth? (check
one) □[Less than $20,000] □[$20,000-$29,999] □[$30,000-$49,999] □ [More than $50,000]
Do you expect the value of your assets to change over the next ten
years? (check one)
□No □Yes, expect to increase □Yes, expect to decrease
If you’re buying this [policy] [certificate] [rider] to protect your
assets and your assets are less than $50,000, experts suggest you think about
other ways to pay for your long-term care.
Disclosure Statement
□ The answers to the questions
above describe my financial situation.
Or
□I choose not to complete
this information.
(Check one.)
□ I agree that the company
and/or its agent (below) has reviewed this worksheet with me including the
premium, premium increase history and potential for premium increases in the future.
I understand the information contained in this worksheet. (This box must be
checked.)
(Note: For direct mail situations, the lead in sentence should be changed
to “I agree that I have reviewed this worksheet including the premium….”)
Signed:____________________________________________________________
(Applicant) (Date)
[□I explained to the applicant
the importance of answering these questions.
Signed:____________________________________________________________
(Agent) (Date)
Agent’s Printed
Name:____________________________________________]
[In order for us to process
your application, please return this signed worksheet to [name of company],
along with your application.]
[My agent has advised me
that this long-term care insurance [policy] [certificate] [rider] does not seem
to be suitable for me. However, I still want the company to consider my
application.
Signed:______________________________________________________________]
(Applicant) (Date)
(Note:
Choose the appropriate sentences depending on whether this is a direct mail or
agent sale.)
Someone from the company may
contact you to discuss your answers and the suitability of this [policy]
[certificate] [rider] for you.
APPENDIX C
Things You Should Know Before You Buy
Long-Term Care Insurance
Long-Term *A long-term care
insurance policy may pay most of the costs of your care in a nursing
Care home. Many policies also pay for care at home or
other community settings. Since
Insurance
polices can vary in coverage, you should read
this policy and make sure you understand
what it covers before you buy it.
*[You should not buy this insurance policy unless you can afford to
pay the premiums
every year.] [Remember that the company can increase
premiums in the future.]
*The personal worksheet
includes questions designed to help you and the company
determine whether this policy is suitable for
your needs.
Medicare *Medicare does not pay for most
long-term care.
Medicaid *Medicaid will generally pay for
long-term care if you have very little income and few
assets. You probably should not buy this policy if
you are now eligible for Medicaid.
*Many people become
eligible for Medicaid after they have used up their own financial
resources by paying for long-term care
services.
*When Medicaid pays your
spouse's nursing home bills, you are allowed to keep your
house and furniture, a living allowance, and
some of your joint assets.
*Your choice of
long-term care services may be limited if you are receiving Medicaid. To
learn more about Medicaid, contact your local
or state Medicaid agency.
Shopper’s
*Make sure the insurance company
or agent gives you a copy of a book called the National
Guide
Association of Insurance Commissioners’ “Shopper's Guide to Long-Term
Care
Insurance”.
Read it carefully. If you have
decided to apply for long-term care
insurance, you have the right to return the
policy within 30 days and get back any
premium you have paid if you are dissatisfied
for any reason or choose not to purchase
the policy.
Counseling *Free counseling and additional
information about long-term care insurance are available
through your state's insurance counseling
program. Contact your state insurance
department or department on aging for more
information about the senior health
insurance counseling program in your state.
Facilities *Some long-term care insurance
contracts provide for benefit payments in certain facilities
only if they are licensed or certified, such
as in assisted living centers. However,
not all
states regulate these facilities in the same
way. Also, many people move into a
different
state from where they purchased their
long-term care insurance policy. Read
the policy
carefully to determine what types of
facilities qualify for benefit payments, and to
determine payment for a covered service will
be made if you move to a state that has a
different
licensing scheme for facilities than the one in which you purchased the policy.
APPENDIX D
Long-Term Care Insurance Suitability Letter
Dear [Applicant]:
Your recent application for
long-term care insurance included a “personal worksheet,” which asked questions
about your finances and your reasons for buying long-term care insurance. For
your protection, state law requires us to consider this information when we
review your application, to avoid selling a policy to those who may not need
coverage.
[Your answers indicate that
long-term care insurance may not meet your financial needs. We suggest that you
review the information provided along with your application, including the
booklet “Shopper’s Guide to Long-Term Care Insurance” and the page titled
“Things You Should Know Before Buying Long-Term Care Insurance. ” Your state
insurance department also has information about long-term care insurance and
may be able to refer you to a counselor free of charge who can help you decide
whether to buy this policy.]
[You chose not to provide any
financial information for us to review.]
We have suspended our final
review of your application. If, after careful consideration, you still believe
this policy is what you want, check the appropriate box below and return this
letter to us within the next 60 days. We will then continue reviewing your
application and issue a policy if you meet our medical standards.
If we do not hear from you
within the next 60 days, we will close your file and not issue you a policy.
You should understand that you will not have any coverage until we hear back
from you, approve your application and issue you a policy.
Please check one box and return in the enclosed envelope.
□ Yes, [although my
worksheet indicates that long-term care insurance may not be a suitable purchase,]
I wish to purchase this coverage. Please resume review of my application.
□ No. I have decided
not to buy a policy at this time. _________________________________________________
___________________________________ APPLICANT’S SIGNATURE DATE
Please return to [issuer] at [address] by [date].
APPENDIX E
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of ______________________________________________
For the Reporting Year of _____________________________________
Company
Name: ___________________________________________ Due: June 30 annually
Company Address: ________________________________________________________________________
_______________________________________________________________________________________
Company NAIC Number: _________________________________________________________
Contact
Person: __________________________________ Phone Number: _____________________
Line of
Business: Individual Group
Instructions
The purpose of this form is
to report all long-term care claim denials under in force long-term care
insurance policies. Indicate the manner of reporting by checking one
of the boxes below:
Per
Claimant - counts each individual who makes one
or a series of claim requests.
Per
Transaction - counts each claim payment request.
“Denied” means a claim that
is not paid for any reason other than for claims not paid for failure to meet
the waiting period or because of an applicable preexisting
condition. It does not include a request for payment that is in excess of the applicable contractual limits.
Inforce Data
|
|
State Data |
Nationwide Data |
|
Total Number of Inforce Policies [Certificates] as of December 31st |
|
|
Claims & Denial Data
|
|
|
State Data |
Nationwide |
|
1 |
Total Number of Long-Term
Care Claims Reported |
|
|
|
2 |
Total Number of Long-Term
Care Claims Denied/Not Paid |
|
|
|
3 |
Number of Claims Not Paid
due to Preexisting Condition Exclusion |
|
|
|
4 |
Number of Claims Not Paid
due to Waiting (Elimination) Period Not Met |
|
|
|
5 |
Net Number of Long-Term
Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4) |
|
|
|
6 |
Percentage of Long-Term
Care Claims Denied of Those Reported (Line 5 Divided by Line 1) |
|
|
|
7 |
Number of Long-Term Care
Claims Denied due to: |
|
|
|
8 |
· Long-Term
Care Services Not Covered under the Policy[2][2] |
|
|
|
9 |
· Provider/Facility
Not Qualified under the Policy[3][3] |
|
|
|
10 |
· Benefit
Eligibility Criteria Not Met[4][4] |
|
|
|
11 |
· Other |
|
|
1. The nationwide data may
be viewed as a more representative and credible indicator where the data for
claims reported and denied for your state are small in number.
2. Example—home health care
claim filed under a nursing home only policy.
3. Example—a facility that
does not meet the minimum level of care requirements or the licensing
requirements as outlined in the policy.
4. Examples—a benefit
trigger not met, certification by a licensed health care practitioner not
provided, no plan of care.
APPENDIX F
Instructions: Insurers shall provide all of the following
information to the applicant regarding premium, premium adjustments, potential
premium increases, and policyholder options in the event of a premium increase
except as noted below. This form does not need to be provided in the event the
policy does not reserve the right to increase rates.
As used in this Appendix:
“Policy” shall mean policy,
certificate, or rider, as applicable.
“Premium” shall include
premium schedules, as applicable.
Companies may substitute
whichever term is appropriate to reflect the long-term care insurance for which
the applicant is applying.
Long-Term Care Insurance
Potential Premium Increase Disclosure Form
This policy is guaranteed
renewable. Companies can increase the
premiums for guaranteed renewable policies in the future. The company cannot increase your premiums because you are older or your health declines. It can increase premiums based on the
experience of all individuals with a policy like yours.
1. What Is Your Premium?
The agent/company has quoted
you a premium of [$________] for this policy. This is not a final premium. The premium might change during the
underwriting process or if you choose different benefits. The premium you’ll be
required to pay for your policy will be [shown on the schedule page of] [will
be attached to] your policy.
2. How Will I Know If My Premium Is Changing?
The company will send you a
notice. The notice will include the new premium and when you will start paying
it. It also will give you ways you could avoid paying a higher premium. One
likely choice will be to keep your insurance policy, but with fewer or lower
benefits than you bought. Another choice may be to stop paying premiums and
have a “paid-up” policy with fewer or lower benefits than the policy you bought.
You may have other choices.
*Contingent Nonforfeiture
If the premium rate for your
policies goes up in the future and you didn't buy a nonforfeiture
option, you may be eligible for contingent nonforfeiture. Here's how
to tell if you are eligible:
You will keep some long-term
care insurance coverage, if:
·
Your premium after the increase exceeds your original premium by the
percentage shown (or more) in the following table; and
·
You lapse (not pay more premiums) within 120 days of the increase.
The amount of coverage
(i.e., new lifetime maximum benefit amount) you will keep will equal the total
amount of premiums you've paid since your policy was first
issued. If you have already received benefits under the policy, so
that the remaining maximum benefit amount is less than the total amount of
premiums you've paid, the amount of coverage will be that remaining
amount.
Except for this reduced
lifetime maximum benefit amount, all other policy benefits will remain at the
levels attained at the time of the lapse and will not increase thereafter.
Should you choose this
Contingent Nonforfeiture option, your policy, with this reduced maximum benefit
amount, will be considered "paid-up" with no further premiums due.
Example:
·
You bought the policy at age 65 and paid the $1,000 annual premium for
10 years, so you have paid a total of $10,000 in premium.
·
In the eleventh year, you receive a rate increase of 50%, or $500 for a
new annual premium of $1,500, and you decide to lapse the policy (not pay any
more premiums).
·
Your "paid-up" policy benefits are $10,000 (provided you have
at least $10,000 of benefits remaining under your policy.)
|
Contingent Nonforfeiture Cumulative Premium Increase over Initial
Premium That qualifies for
Contingent Nonforfeiture (Percentage increase is cumulative from date of original
issue. It does NOT represent a one-time increase.) |
|
|
Issue Age |
Percent Increase Over Initial Premium |
|
29 and under |
200% |
|
30-34 |
190% |
|
35-39 |
170% |
|
40-44 |
150% |
|
45-49 |
130% |
|
50-54 |
110% |
|
55-59 |
90% |
|
60 |
70% |
|
61 |
66% |
|
62 |
62% |
|
63 |
58% |
|
64 |
54% |
|
65 |
50% |
|
66 |
48% |
|
67 |
46% |
|
68 |
44% |
|
69 |
42% |
|
70 |
40% |
|
71 |
38% |
|
72 |
36% |
|
73 |
34% |
|
74 |
32% |
|
75 |
30% |
|
76 |
28% |
|
77 |
26% |
|
78 |
24% |
|
79 |
22% |
|
80 |
20% |
|
81 |
19% |
|
82 |
18% |
|
83 |
17% |
|
84 |
16% |
|
85 |
15% |
|
86 |
14% |
|
87 |
13% |
|
88 |
12% |
|
89 |
11% |
|
90 and over |
10% |
[The following contingent
nonforfeiture disclosure need only be included for those limited pay policies
to which Ins 3601.27(d)(4) and (d)(6) of the
rule are applicable].
In addition to the
contingent nonforfeiture benefits described above, the following reduced
"paid-up" contingent nonforfeiture benefit is an option in all
policies that have a fixed or limited premium payment period, even if you
selected a nonforfeiture benefit when you bought your policy. If
both the reduced "paid-up" benefit AND the contingent benefit
described above are triggered by the same rate increase, you can chose either of the two benefits.
You are eligible for the
reduced "paid-up" contingent nonforfeiture benefit when all three conditions
shown below are met:
1. The premium
you are required to pay after the increase exceeds your original premium by the
same percentage or more shown in the chart below:
Triggers for a Substantial Premium Increase
|
Issue Age |
Percent
Increase Over
Initial Premium |
|
Under 65 |
50% |
|
65-80 |
30% |
|
Over 80 |
10% |
2. You stop
paying your premiums within 120 days of when the premium increase took effect;
AND
3. The ratio of
the number of months you already paid premiums is 40% or more than the number
of months you originally agreed to pay.
If you exercise this option your coverage will be converted to reduced
"paid-up" status. That means there will be no additional
premiums required. Your benefits will change in the following ways:
a. The total lifetime amount of benefits your
reduced paid up policy will provide can be
determined by multiplying 90% of
the lifetime benefit amount at the time the policy becomes paid up by the ratio
of the number of months you
already paid premiums to the number of months you agreed to pay them.
b. The daily benefit amounts you purchased will
also be adjusted by the same ratio.
If you purchased lifetime
benefits, only the daily benefit amounts you purchased will be adjusted by the
applicable ratio.
Example:
· You bought the policy at age
65 with an annual premium payable for 10 years.
· In the sixth year, you
receive a rate increase of 35% and you decide to stop paying premiums.
· Because you have already
paid 50% of your total premium payments and that is more than the 40% ratio,
your "paid up" policy benefits are .45 (.90 times .50) times the total
benefit amount that was in effect when you stopped paying your
premiums. If you purchased inflation protection, it will not continue to apply to the benefits in the reduced
"paid-up" policy.
APPENDIX G
Long-Term Care Insurance
Replacement and Lapse Reporting Form
For the State of
________________________ For the Reporting Year of _____________________
Company
Name: __________________________________ Due: June
30 annually
Company Address: _____________________________Company
NAIC Number: ____________
Contact
Person: ______________________________Phone
Number: (___)____________
Instructions:
The purpose of this form is
to report on a statewide basis information regarding long-term care insurance
policy replacements and lapses. Specifically, every insurer shall
maintain records for each producer on that producer's amount of long-term care
insurance replacement sales as a percent of the producer's total annual sales
and the amount of lapses of long-term care
insurance policies sold by the producer as a percent of the producer's total
annual sales. The tables below should be used to report the ten
percent (10%) of the insurer's producers with the greatest percentages of
replacements and lapses.
Listing of the 10% of
Producers with the Greatest Percentage of Replacements
|
Producer's Name |
Number of Policies Sold By This
Producer |
Number of Policies Replaced By This
Producer |
Number of Replacements As % of Number Sold By This Producer |
|
|
|
|
|
Listing of the 10% of
Producers with the Greatest Percentage of Lapses
|
Producer's Name |
Number of Policies Sold By This
Producer |
Number of Policies Lapsed by This Producer |
Number of Lapses As % of Number Sold By This Producer |
|
|
|
|
|
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales
____%
Percentage of Replacement Policies Sold to Policies In Force (as of the end of the preceding
calendar year) ____%
Percentage of Lapse Policies to Total Annual Sales _____%
Percentage of Lapse Policies to Policies in Force (as of the end
of the preceding calendar year) ____%
APPENDIX H
Guidelines for Long-Term Care Independent Review Entities
In order
for an
organization to qualify as an independent review organization for long-term
care insurance benefits trigger decisions, it shall comply with all of the
following:
a. The
independent review organization shall ensure that all health care professionals
on its staff and with whom it contracts to provide benefit trigger
determination reviews hold a current unrestricted license or certification to
practice a health care profession in the United States.
b. The
independent review organization shall ensure that any health care professional
on its staff and with whom it contracts to provide benefit trigger
determination reviews who is a physician holds a current certification by a
recognized American medical specialty board in a specialty appropriate for
determining an insured's functional or cognitive impairment.
c. The
independent review organization shall ensure that any health care professional
on its staff and with whom it contracts to provide benefit trigger
determination reviews who is not a physician holds a current certification in
the specialty in which that person is licensed, by a recognized American
specialty board in a specialty appropriate for determining an insured's
functional or cognitive impairment.
d. The
independent review organization shall ensure that all health care professionals
on its staff and with whom it contracts to provide benefit trigger
determination reviews have no history of disciplinary actions or sanctions including,
but not limited to, the loss of staff privileges or any participation
restriction taken or pending by any hospital or state or federal
government regulatory agency.
e. The
independent review organization shall ensure that neither it, nor any of its
employees, agents, or licensed health care professionals utilized for benefit
trigger determination reviews receives compensation of any type that is
dependent on the outcome of the review.
f. The
independent review organization shall ensure that neither it, nor any of its
employees, agents, or licensed health care professionals it utilizes for
benefit trigger determination reviews are in any manner related to, employed by
or affiliated with the insurer, insured or with a person who previously provided
medical care or long term care services to
the insured.
g. The independent
review organization shall provide a description of the qualifications of the
reviewers retained to conduct independent review of long-term care insurance
benefit trigger decisions, including the reviewer's current and past employment
history, practice affiliations and a description of past
experience with decisions relating to long-term care, functional
capacity, dependency in activities of daily living, or in assessing cognitive
impairment. Specifically, with regard to reviews
of tax qualified long-term care insurance contracts, it must demonstrate the
ability to assess the severity of cognitive impairment requiring substantial
supervision to protect the individual from harm, or with assessing deficits in
the ability to perform without substantial assistance from another person at
least two activities of daily living for a period of at least 90 days due to a
loss of functional capacity.
h. The
independent review organization shall provide a description of the procedures
employed to ensure that reviewers conducting independent reviews are appropriately
licensed, registered or certified; trained in the principles, procedures and
standards of the independent review organization; and knowledgeable about the
functional or cognitive impairments associated with the diagnosis and disease
staging processes, including expected duration of such impairment, which is the
subject of the independent review.
i. The independent
review organization shall provide the number of reviewers retained by the independent
review organization and a description of the areas of expertise available from
such reviewers and the types of cases such reviewers are qualified to review
(e.g., assessment of cognitive impairment or inability to perform activities of
daily living due to a loss of functional capacity).
j. The independent
review organization shall provide a description of the policies and procedures
employed to protect confidentiality of protected health information, in
accordance with federal and state law.
k. The
independent review organization shall provide a description of its quality
assurance program.
l. The
independent review organization shall provide the names of all corporations and
organizations owned or controlled by the independent review organization or
which own or control the organization, and the nature and extent of any such
ownership or control. The independent review organization shall
ensure that neither it, nor any of its employees, agents, or licensed health
care professionals utilized are not a subsidiary of, or owned or controlled by,
an insurer or by a trade association of insurers of which the insured is a
member.
m. The
independent review organization shall provide the names and resumes of all
directors, officers and executives of the
independent review organization.
PART Ins 3602 NEW HAMPSHIRE LONG-TERM CARE PARTNERSHIP
PROGRAM
Statutory Authority: RSA 400-A:15, I.; RSA 415-D:5; RSA 415-D:12;
42 U.S.C. §1396p(b)(1)(C)(iii)
Ins 3602.01 Purpose. The purpose of this part is to implement
filing, notice, and exchange requirements for the New Hampshire long-term
care partnership program.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.02 Applicability
and Scope. This part shall be
applicable to all long-term care insurance policies and to any policy or certificate that will be marketed and sold
under the New Hampshire long-term care partnership program.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.03 Definitions.
(a)
"Commissioner" means the commissioner of the New Hampshire insurance
department.
(b)
"Exchange" means an exchange of a long-term care policy or
certificate that was issued on or after February 8, 2006, including an exchange
of a non-certified partnership policy or certificate, for a New Hampshire
partnership policy or certificate.
(c) "Long-term
care insurance" means "long-term care insurance" as defined
under RSA 415-D:3, V.
(d) "New
Hampshire long-term care partnership program" means a program established
under the Federal Deficit Reduction Act of 2005 and approved under Medicaid
State Plan Amendment 07-009.
(e)
"Non-certified partnership policy or certificate" means
insurance coverage under a long-term care policy or certificate that was issued
in New Hampshire on or after February 8, 2006, and contains all
necessary provisions, including the necessary inflation protection
requirements, to qualify as New Hampshire partnership coverage pursuant to
§1917(b)(1)(C)(iii) of the Social Security Act, 42 U.S.C. §1396p(b)(1)(C)(iii),
but where the policy or certificate form has not yet been approved by the New
Hampshire insurance department as a New Hampshire partnership policy or
certificate.
(f) "New
Hampshire partnership policy or certificate" means long-term care coverage
that qualifies as a partnership policy or certificate pursuant to
§1917(b)(1)(C)(iii) of the Social Security Act, 42 U.S.C. §1396p
(b)(1)(C)(iii) and has been filed and approved by the insurance department as a
partnership policy or certificate under the New Hampshire long-term care
partnership program.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.04 Notification, Offer of Exchange.
(a) Except as
provided in (b), within 365 calendar days from the date that an insurer begins
to advertise, market, offer, or sell coverage under the New Hampshire long-term
care partnership program, the insurer shall offer, on a one-time basis to
all policyholders or certificateholders that were
issued long-term care insurance on or after February 8, 2006, the option to
exchange existing long term-care coverage for a New Hampshire partnership
policy or certificate as follows:
(1) An insurer shall advise policyholders by
written notice of their right to exchange their current long-term care policy
for a partnership policy;
(2) This notice shall include a provision giving
the policyholder up to 90 calendar days from the date of the notice to make
their intention to exchange known to the insurance company;
and
(3) If the policy is a group long-term care
policy and an exchange is permitted by the policyholder, each certificateholder shall be given notice of the option to
exchange the certificate for a certificate providing partnership coverage
within 90 calendar days of the mailing of the notice by the insurer.
(b) Within 90
calendar days from the date that an insurer
begins to advertise, market, offer, or sell coverage under the New Hampshire long-term care partnership
program, the insurer shall deliver to any policyholder or certificateholder
who was issued a non-certified partnership policy or certificate, an
endorsement approved under Ins 3602.07(b) together with a notice that informs
the policyholder or certificateholder that the policy
or certificate qualifies as a New Hampshire partnership policy or certificate.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.05 Exchanges.
(a) The insurer
shall exchange long-term care coverage that was purchased on or after February
8, 2006 for partnership coverage in one of the following
ways:
(1) For all non-certified partnership policies or
certificates, by adding an endorsement that all the provisions required to
qualify the policy as a New Hampshire partnership policy have been met and the
policy is a New Hampshire partnership policy; or
(2) By exchanging an existing policy or certificate for a new partnership policy or certificate
or by adding a rider or endorsement to an existing policy or certificate.
(b) The following
provisions shall apply to any exchange:
(1) If the new coverage has an actuarial value of
benefits equal to or lesser than the actuarial value of benefits of the
existing coverage, based on uniform assumptions as determined on the date of
issue for a new insured, then:
a.. The new policy or certificate shall not be
underwritten; and
b. The rate charged for the new policy or
certificate shall be determined using the original issue age and risk class of
the insured that was used to determine the rate of the existing policy;
(2) If the new coverage has an actuarial value of
benefits exceeding the actuarial value of benefits of the existing coverage,
based on uniform assumptions, as determined on the date of issue for a new
insured, then:
a. The insurer shall apply its new business,
long-term care underwriting guidelines to the increased benefits only; and
b. The rate charged for the new policy or
certificate shall be determined using the method set forth in subparagraph
(b)(1)b. above for the existing
benefits, increased by the rate for the increased benefits using the current
attained age and risk class of the insured for the increased benefits only;
(3) Any exchange offer shall
be made to all policyholders and certificateholders
on a nondiscriminatory basis;
(4) Except for an exchange of a non-certified
partnership policy or certificate pursuant to (a)(1) of this section, an
exchange offer shall be deferred for any policyholder or certificateholder
who is currently within an elimination period under the policy or is receiving
benefits under the policy. Such deferral
shall continue so long as the eligibility for benefits or elimination period exists;
(5) In addition to the requirements of this part,
all exchanges shall comply with the requirements of Ins
3601, provided however that Ins 3601.23 shall not apply to the exchange of a
non-certified partnership policy or certificate for a New Hampshire partnership
policy or certificate when the new coverage has an actuarial value of benefits
equal to or lesser than the actuarial value of benefits of the original
non-certified partnership policy or certificate;
(6) The new coverage offered shall be on a New
Hampshire partnership policy or certificate form that is approved for sale in
the general market;
(7) The insurer shall issue the disclosure notice
as set forth in Ins 3602.06(a)(2); and
(8) The insured shall not lose any rights,
benefits, or built-up value that have accrued under the original policy
with respect to the benefits provided under the original policy, including, but
not limited to, rights established because of the lapse of time related to
pre-existing condition exclusions, elimination periods, or incontestability
clauses.
(c) Policies issued
pursuant to this section shall be considered exchanges and not replacements.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.06 Standards
and Reporting Requirements for Approved Long-Term Care Partnership Policies and
Certificates.
(a) The following
standards shall apply to all insurers that issue or deliver New Hampshire
partnership policies or certificates:
(1) In addition to the required filing and
approval pursuant to this part, any policy or certificate marketed or
represented to be a New Hampshire partnership policy or certificate shall
comply with the following requirements:
a. The insured individual shall be a resident of
New Hampshire when coverage first becomes effective under the policy. If the policy or certificate is exchanged
pursuant to Ins 3602.05, the individual shall have
been a resident of New Hampshire when coverage first became effective under the
original policy;
b. The coverage shall be intended to be a
qualified long-term care insurance coverage under the provisions of Ins 3601.05 (a)(5); and
c. The policy or certificate shall be issued
with and shall retain inflation coverage that meets the inflation standards
specified in Ins 3601.12;
(2) The following notices shall be required:
a. A disclosure notice that explains the
benefits associated with the policy or certificate and indicates that,
at the time issued, the policy qualified as a New Hampshire partnership
policy. The required disclosure notice
shall appear verbatim as follows:
“Partnership Status Disclosure Notice for Long-Term Care
Partnership Policies/Certificates
IMPORTANT INFORMATION REGARDING THE NEW HAMPSHIRE
LONG-TERM CARE PARTNERSHIP PROGRAM
Note: It is very important that
you keep this Disclosure Notice with your Long-Term Care Insurance Policy or
Certificate.
Insured Name: ___________________________________________
Policy Name: ____________________________________________
Date of Issue: ____________________________________________
The long-term care insurance policy/certificate that you have purchased
currently qualifies for the New Hampshire Long-Term Care Partnership
Program.
Insurance companies voluntarily
agree to participate in the Partnership Program by offering long-term care
insurance coverage that meets certain State and Federal requirements. Policies that qualify as Partnership Policies
protect your assets through a feature known as an "asset disregard"
under the New Hampshire Medicaid program.
Asset Disregard "Asset Disregard"
means that an amount of your assets equal to the amount of long-term care
insurance benefits you have received under your Partnership Policy will not be
counted for the purpose of determining your eligibility for Medicaid. This generally allows you to keep additional
assets equal to the insurance benefits received under your Partnership Policy
without affecting your eligibility for Medicaid. All other Medicaid eligibility criteria will
still apply. This "Asset Disregard"
is only available if you have a Partnership Policy. The purchase of a Partnership Policy
guarantees that if you qualify for the Medicaid program, you can retain
additional assets as described above.
However, the purchase of a Partnership Policy does not automatically
qualify you for the Medicaid program.
Partnership Policy/Certificate Status. Your long-term care insurance policy is a
Partnership Policy under the New Hampshire Long-Term Care Partnership Program
as of your policy's effective date.
What Could Disqualify Your Policy from the Partnership
Program. If you make any changes to your
policy/certificate, such changes could affect whether your policy continues to
be a Partnership Policy. Before you make any changes, you should
consult with [name of insurance company] to determine the effect of the
proposed change. In addition, if you
move to a state that does not maintain a Partnership Program or does not
recognize your policy as a Partnership Policy, you may not receive beneficial
treatment such as asset disregard under the Medicaid program in that state.
The information contained in this notice is
based on New Hampshire and Federal laws in effect the date your policy was
issued. These laws are subject to
change.
Additional Information. If you have any questions regarding your
insurance policy/certificate please contact [insert
name of insurer]. If you have questions
regarding current laws governing Medicaid eligibility, you should contact the:
New Hampshire Department of
Health and Human Services
Division of Family Assistance
Brown Building, 129 Pleasant
Street, Concord, NH (street address)
129 Pleasant Street,
Concord, NH 03301-3857 (mailing address)
Telephone: 603-271-9700 or 800-852-3345, ext. 9700”
b. The following requirements and procedures
shall apply to (2)a. above:
1. The insurer shall provide the insured’s name,
the policy name, and the date of issue in the spaces provided in the disclosure
notice;
2. The text in the notice shall be in at least
12-point type and shall follow the order of the information presented in (2)a.;
and
3. An insurer may modify the format but shall
not change the order of the mandated text from that specified in (2)a.,
if the insurer files the form for review and approval by the commissioner in
compliance with Ins 401.13;
c. When an insurer is made aware that a
policyholder or certificateholder has initiated
action that will result in the loss of partnership status, the insurer shall
provide an explanation of how such action impacts the insured in writing. The insurer shall also advise the policyholder
or certificateholder on how to retain partnership
status if possible;
d. If a partnership policy subsequently loses
partnership status, the insurer shall explain to the policyholders or certificateholders in writing within 60 calendar days of
the loss the reason for the loss of status;
e. All insurers shall provide upon request and
without charge to any insured under a New Hampshire partnership policy or
certificate, or to any New Hampshire resident insured under a long-term care
insurance policy or certificate that is afforded reciprocity pursuant to the
standards established under 42 U.S.C. §1396p(b)(1)(C)(iii), a written summary
of policy information that shall include the following:
1. The name of the insured;
2. The policy or certificate number;
3. The effective date of coverage;
4. The state in which the policy or certificate
was issued;
5. The age of the insured at the time the
coverage was issued;
6. In regard to any inflation coverage, the
following information:
(i) Whether the policy was issued with or without
inflation coverage;
(ii) A description of any inflation coverage currently
in effect; and
(iii) Whether any inflation coverage provided is
simple inflation coverage or compound inflation coverage;
f. Whether the policy is intended to meet the
standards of a tax qualified long-term care policy;
g. The cumulative dollar amount of insurance benefits
paid to the insured only, excluding any payments for cash surrender, return of
premium death benefit, or waiver of premium.
The date such cumulative dollar amount was calculated shall also be provided;
h. The total dollar amount of insurance benefits
remaining available under the policy, and the date such total remaining
benefits were calculated;
i. The date the form was completed; and
j. The name, address, telephone,
and email address of the person completing the form; and
(3) Under §1917(b)(5)(B)(iii) of the Social
Security Act 42 U.S.C. §1396p(b)(5)(B)(iii), the commissioner, in implementing
the New Hampshire long-term care partnership program, shall certify that long-term care insurance policies and
certificates covered under the partnership program meet certain consumer
protection requirements, and policies. The consumer protection requirements shall be
as set forth in §1917(b)(5)(A) of the Social Security Act and principally
include certain specified provisions of the National Association of Insurance
Commissioners long-term care model act 640 and model regulation 641, as updated
in 2017 and available as referenced in Appendix II. In providing this certification, the
commissioner shall require the certification by insurers made in accordance
with Appendix III Long-Term Care Partnership Program Insurer Certification
Form.
(b) In accordance
with §1917(b)(1)(C)(iii)(VI) and (v) of the Social Security Act, all issuers of
partnership policies or certificates shall provide regular reports to the
secretary of the Federal Department of Health and Human Services (secretary) in
accordance with 45 CFR Part 144, Subpart B.
(c) Such information
shall include, but not be limited to, the following:
(1) Notification regarding when insurance benefits
provided under partnership policies or certificates have been paid and the
amount of such benefits paid; and
(2) Notification regarding when such policies or
certificates otherwise terminate.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.07 Inflation Protection Requirements for
Long-Term Care Partnership Policies and Certificates. Pursuant to
§1917(b)(1)(C)(iii)(IV) of the Social Security Act 42 U.S.C.
§1396p(b)(1)(C)(iii)(IV), an insurer shall not issue a policy or certificate
marketed or represented as a partnership policy unless the policy or
certificate complies with the following inflation protection requirements:
(a) For a person who
is less than 61 years of age, as of the date of purchase, the policy or
certificate shall provide compound annual inflation protection from the date of
purchase as follows:
(1) At the time of purchase, insurers shall offer
to each applicant the option to purchase compound annual inflation protection
that automatically increases each year on a compounded basis at a rate of not less
than 5.0 percent annually throughout the interval of coverage. The inflation protection shall automatically
increase benefits each year on a compounded basis;
(2) If the applicant declines the offer of inflation
protection specified in (1) above, then the insurer shall offer and the
applicant shall purchase and retain compound annual inflation protection until
the insured attains age 61 or goes on claim status, whichever comes first. The inflation protection is required to
automatically increase benefits each year on a compounded basis at a rate that
the insured elects, which may be in a range from one percent to 4 percent or
tied to the consumer price index for all urban consumers (CPI-U); and
(3) A person who is less than 61 years of age
that has purchased a long-term care partnership policy or certificate with the
required compound inflation protection specified in this paragraph may, upon
attaining 61 years of age, choose to amend the compound inflation protection
provision in the policy or certificate in accordance with the requirements
specified in (b) below.
(b) For a person who
is at least 61 years of age but less than 76 years of age as of the date of
purchase, the policy or certificate shall provide an acceptable level of
inflation protection from the date of purchase as follows:
(1) Regardless of the insured's health status,
the insurer shall offer and the insured shall purchase
and retain inflation protection until the insured attains age 76 or goes on
claim status, whichever comes first;
(2) Acceptable coverage shall include automatic
annual inflation protection, either simple or compound, paid with either level
or stepped premium;
(3) Inflation protection as required by this
paragraph shall be in a range of from one percent to 5 percent or tied to the
consumer price index for all urban consumers (CPI-U); and
(4) A person who is less than 76 years of age
that has purchased a long-term care partnership policy or certificate with the
required inflation protection specified in this paragraph may, upon attaining
76 years of age, choose to amend the inflation protection provision in the
policy or certificate in accordance with the requirements specified in (c)
below.
(c) For any person who
has attained the age of 76, inflation protection may be provided but is not
required. However, the long-term care
inflation protection option specified in Ins 3601.12
relating to Requirement to Offer Inflation Protection shall be offered to any
applicant for a partnership policy who has attained the age of 76.
(d) An option to
purchase inflation protection at a future time shall not constitute compliance
with the inflation protection requirements set forth in (a) and (b) above.
(e) The inflation protection
provisions in this section shall not be available under the following policies:
(1) Riders for group and individual annuities and
life insurance policies that provide long-term care insurance; and
(2) Life insurance policies:
a. That accelerate the death benefit for one or
more of the qualifying events of terminal illness, medical conditions requiring
extraordinary medical intervention, or permanent institutional confinement;
b. That provide the option of a lump-sum payment
for those benefits; and
c. Where neither the benefits nor the
eligibility for the benefits is conditioned upon the receipt of long-term care.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.08 Filing
Requirements for Long-Term Care Partnership Policies.
(a) Each New Hampshire
partnership policy or certificate, including any long-term care partnership
endorsement issued or delivered, shall comply with the following requirements
before being issued or delivered:
(1) Each New Hampshire partnership policy,
certificate, or endorsement shall be filed with the department and approved by
the commissioner in accordance with the requirements and procedures set forth
in Ins 401.13; and
(2) Each New Hampshire partnership policy,
certificate, or endorsement filing shall include a Long-Term Care Partnership
Program Insurer Certification Form, as specified in Appendix III, which shall
comply with the following requirements and procedures:
a. The text in the certification form shall be
in at least 10-point type and shall follow the order of the information
presented in Appendix III. The text in
the certification form as specified in Appendix III shall be mandatory; and
b. An insurer may modify the format but shall
not change the order of the mandated text from that specified in Appendix
III, if the insurer files the certification form for review and approval by the
commissioner in compliance with Ins 401.13.
(b) A previously
approved non-certified partnership policy or certificate form shall be approved
as a New Hampshire partnership policy or certificate form upon the filing and
approval of:
(1) The Long-Term Care Partnership Program
Insurer Certification Form set forth in Appendix III;
(2) An endorsement identifying the policy as a
New Hampshire partnership policy; and
(3) The previously approved policy or policy and
certificate if the policy is a group policy.
(c) Insurers shall
notify the commissioner, via an informational System for
Electronic Rate and From Filing (SERFF) filing, within 15 calendar days of
beginning to advertise, market, offer, or sell partnership policies under
the New Hampshire long-term care partnership program.
Source. #9654, eff 2-16-10; ss by #12472, eff 2-16-18
Ins 3602.09 Waiver
or Suspension of Rules.
(a) The
commissioner, upon the commissioner’s own initiative or upon request by an
insurer, shall waive any requirement of this part if such waiver does not
contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause
confusion or would be misleading to consumers;
(2) The rule provision is in whole or in part inapplicable
to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the
rule would be onerous without promoting the objective or intent of the rule
provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b) No requirement
prescribed by statute shall be waived unless expressly authorized by law.
(c) Any person or
entity seeking a waiver shall make a request in writing.
(d) A request for a
waiver shall specify the basis for the waiver and proposed alternative, if any.
Source. #12472, eff 2-16-18
APPENDIX I
|
Rule |
Specific State Statute the Rule Implements |
|
Ins 3601.01 |
RSA 400-A:15, I; RSA 415-D:1 |
|
Ins 3601.02 |
RSA 400-A:15, I; RSA 415-D:2 |
|
Ins 3601.03 |
RSA 400-A:15, I; RSA 415-D:3 |
|
Ins 3601.04 |
RSA 400-A:15, I; RSA 415-D:5 |
|
Ins 3601.05 |
RSA 400-A:15, I; RSA 415-D:5 through 10 |
|
Ins 3601.06 |
RSA 400-A:15, I; RSA 415-D:10 |
|
Ins 3601.07 |
RSA 400-A:15, I; RSA 415-D:5 |
|
Ins 3601.08 |
RSA 400-A:15, I; RSA 415-D:3, 5 and 6 |
|
Ins 3601.09 |
RSA 400-A:15, I; RSA 415-D:11 |
|
Ins 3601.10 |
RSA 400-A:15, I; RSA 415-D:5 |
|
Ins 3601.11 |
RSA 400-A:15, I; RSA 415-D:5 and 8 |
|
Ins 3601.12 |
RSA 400-A:15, I; RSA 415-D:8 |
|
Ins 3601.13 |
RSA 400-A:15, I; RSA 415-D:6 and 7 |
|
Ins 3601.14 |
RSA 400-A:15, I; RSA 415-D:12 |
|
Ins 3601.15 |
RSA 400-A:15, I; RSA 402-J; RSA 415-D:12 |
|
Ins 3601.16 |
RSA 400-A:14; RSA 400-A:15, I; 415-D:1 and 12 |
|
Ins 3601.17 |
RSA 400-A:15, I; RSA 410; 415-D:12 |
|
Ins 3601.18 |
RSA 400-A:15, I; RSA 415-D:3, VI; RSA 415-D:5, IV(e) |
|
Ins 3601.19 |
RSA 400-A:15, I; RSA 415-D:3 and 8; RSA 415-D:3; RSA
415-D:8 |
|
Ins 3601.20 |
RSA 415-D:4, 11 and 12 |
|
Ins 3601.21 |
RSA 400-A:15, I; RSA 415-D:1 and 3, V; RSA 415-D:12 |
|
Ins 3601.22 |
RSA 400-A:15, I; RSA 415-D:1 and 3, V; RSA 415-D:5,
8, 11 and 12 |
|
Ins 3601.23 |
RSA 400-A:15, I; RSA 415-D:1 and 3, VIII; RSA 415-D:5 |
|
Ins 3601.24 |
RSA 400-A:15, I; RSA 415-D:5 |
|
Ins 3601.25 |
RSA 400-A:15, I; RSA 415-D:5; 415-D:8 |