New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 15 - LONG-TERM CARE INSURANCE
Section 13.10.15.50 - APPENDIX B

Universal Citation: 13 NM Admin Code 13.10.15.50
Current through Register Vol. 35, No. 18, September 24, 2024

LONG TERM CARE INSURANCE PERSONAL WORKSHEET People buy long-term care insurance for a variety of reasons. These reasons include to avoid spending assets for long-term care, to make sure there are choices regarding the type of care received, to protect family members from having to pay for care, or to decrease the chances of going on Medicaid. However, long term care insurance can be expensive, and is not appropriate for everyone. By state law, the insurance company must fill out part of the information on this worksheet and ask you to fill out the rest to help you and the insurance company decide if you should buy this policy. Premium Information Policy Form Number(s)_____________________________ The premium for the coverage you are considering will be [$______ per month, or $____per year,] [a one-time single premium of $_____.] Type of Policy (noncancellable/guaranteed renewable):__________________________ The Company's Right to Increase Premiums:_________________________________ [The company cannot raise your rates on this policy.] [The company has a right to increase premiums on this policy form in the future, provided it raises rates for all policies in the same class in this state.] [Insurers shall use appropriate bracketed statement. Rate guarantees shall not be shown on this form.] Rate Increase History The company has sold long-term care insurance since [year] and has sold this policy since [year]. [The company has never raised its rates for any long-term care policy it has sold in this state or any other state.] [The company has not raised its rates for this policy form or similar policy forms in this state or any other state in the last 10 years] [The company has raised its premium rates on this policy form or similar policy forms in the last 10 years. Following is a summary of the rate increase(s).] Questions Related to Your Income How will you pay each years' premiums? ___ From My Income ___ From My Savings\Investments ___ My Family will Pay [Have you considered whether you could afford to keep this policy if the premiums were raised, for example, by 20%?] What is your annual income? (check one) ___ Under $10,000 ___ $10-20,000 ___ $20-30,000 ___ $30-50,000 ___ Over $50,000 How do you expect your income to change over the next 10 years? (check one) ___ No change ___ Increase ___ Decrease 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 if the premiums will be more than 7% of your income. Will you buy inflation protection? (check one) ____ yes ____ no If not, have you considered how you will pay for the difference between future costs and your daily benefit amount? ___ From My Income ___ From My Savings\Investments ___ My Family will Pay The national average annual cost of 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 are you considering? Number of days _____ Approximate cost $____________ for that period of care. How are you planning to pay for your care during the elimination period? ___ From My Income ___ From My Savings\Investments ___ My Family will Pay Questions Related to Your Savings and Investments Not counting your home, what is the approximate value of all of your assets (savings and investments)? (check one) ___ Under $20,000 ___ $20-30,000 ___ $30-50,000 ___ Over $50,000 How do you expect your assets to change over the next ten years? ___ Stay about the same ___ Increase ___ Decrease If you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long-term care. Disclosure Statement ___ The answers to the questions above describe my financial situation. or ___ I choose not to complete this information. ___ I acknowledge that the carrier and/or its agent (below) has reviewed this form with me including the premium, premium rate increase history and potential for premium rate increases in the future. [For direct mail situations, use the following: I acknowledge that I have reviewed this form including the premium, premium rate increase history and the potential for premium rate increases in the future.] I understand the above disclosures. I understand that the rates for this policy may increase in the future. (This box must be checked). Signed:_______________________________________ Date: _________________________ (Applicant) [___ I explained to the applicant the importance of completing this information. Signed:______________________________________ Date:__________________________ (Agent) Agent's printed name ________________________________________________________] [In order for us to process your application, please return this signed statement to [name of company], along with your application.] [My agent has advised me that this policy does not appear to be suitable for me. However, I still want the company to consider my application.] Signed:______________________________________ Date:__________________________ (Applicant) The company may contact you to verify your answers.

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