New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 3600 - LONG-TERM CARE INSURANCE
Part Ins 3602 - NEW HAMPSHIRE LONG-TERM CARE PARTNERSHIP PROGRAM
Appendix III - Long-Term Care Partnership Program Insurer Certification Form

Section 1917(b)(5)(B)(iii) of the Social Security Act, 42 U.S.C. § 1396p(b)(5)(B)(iii), authorizes the New Hampshire insurance commissioner upon implementing a qualified state long-term care partnership program ("qualified partnership") to certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the qualified partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy such requirements. These consumer protection requirements are set forth in §1917(b)(5)(A) of the Social Security Act, 42 U.S.C. § 1396p(b)(5)(A) and principally include certain specific provisions of the long-term care insurance model regulation and long-term care insurance model act promulgated by the National Association of Insurance Commissioners, referred to herein as the "Model Regulation 641" and "Model Act 640" respectively, and available as referenced in Appendix II.

In order to provide the Insurance Commissioner with information necessary to provide a certification for policies, this issuer certification form requests information and a certification from issuers of long-term care insurance policies with respect to policy forms that may be covered under the qualified partnership program of the state.

An insurance company may request certification of policies from time to time and, accordingly, may supplement this issuer certification form, e.g., as it introduces new long-term insurance policy forms for issuance.

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II. QUESTIONS REGARDING APPLICABLE PROVISIONS OF THE MODEL REGULATION 641 AND MODEL ACT 640

Please answer each of the questions below with respect to the policy forms identified in section I.C. above. For purposes of answering the questions below, any provision of the Model Regulation 641 or Model Act 640 listed below shall be treated as including any other provision of the Model Regulation 641 or Model Act 640 necessary to implement the provision.

Are the following requirements of the Model Regulation 641 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in Section I.C. above?

Are the following requirements of the Model Act 640 met with respect to all policies (including certificates issued under a group insurance contract) intended to be covered under the qualified partnership program that are issued on each of the policy forms identified in section I.C. above?

In order for a policy to be covered under the qualified partnership program of the state, the answers to all questions above should be "yes" (or "N/A" where all requirements with respect to a provision are not applicable). If answers differ between policy forms (e.g., a requirement would be answered "Yes" for one form and "N/A" for another), you should use separate issuer certification forms for such policies.

III. CERTIFICATION

I hereby certify that the policy forms and endorsements identified in section C. above meet all of the requirements of the National Association of Insurance Commissioners' Long-Term Care Model Act 640 and Model Regulation 641 that are specified in 42 U.S.C. § 1396p(b)(l)(C)(iii) and further certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete.

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[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.