Current through Register Vol. 50, No. 9, September 20, 2024
A.Section
1963 of the regulation
implements, interprets, and makes specific the provisions of
R.S.
22:1186(G) in prescribing a
standard format and the content of an outline of coverage.
B. The outline of coverage shall be a
free-standing document, using no smaller than 10-point type.
C. The outline of coverage shall contain no
material of an advertising nature.
D. 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.
E. Use of the text and sequence of text of
the standard format outline of coverage is mandatory, unless otherwise
specifically indicated.
F. Format
for outline of coverage:
[COMPANY NAME] [ADDRESS-CITY AND 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, must
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.
(a) 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
(b)
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 INCREASETHE PREMIUM
YOUPAY.
(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 deductible(s),
waiting periods, elimination periods and benefit maximums.]
(b) [Institutional benefits, by skill
level.]
(c) [Noninstitutional
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 must 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)
Pre-existing conditions;
(b)
Noneligible facilities and provider;
(c) Noneligible 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 which limit, exclude, restrict, reduce, delay, or in any
other manner operate to qualify payment of the benefits described in Number 9
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 annual premium which
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.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:1186(A),
22:1186(E),
22:1188(C),
22:1189,
and
22:1190.
