Current through Register Vol. XLI, No. 38, September 20, 2024
This section of the rule implements, interprets and makes
specific, the provisions of W. Va. Code §
33-15A-6(g)(1)(A)
in prescribing a standard format and the content of an outline of coverage.
31.1. The outline of coverage shall be a
free-standing document, using no smaller than ten point type.
31.2. The outline of coverage shall contain no
material of an advertising nature.
31.3.
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.
31.4.
Use of the text and sequence of text of the standard format outline of coverage is
mandatory, unless otherwise specifically indicated.
31.5. 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, 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.
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 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)
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 which 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 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.
