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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > LTC03G & LTC03I - Group and Individual Long Term Care/Partnership

 

LONG-TERM CARE FORM FILING CHECKLIST AND CERTIFICATION
For Both Non-Partnership and Partnership Program Form Filings
(Amended 11/2011)

 

                 

Company Name:

Policy Form(s) covered by this certification:

Will the form(s) be offered as Partnership coverage?
yes_____                     no_____

 

 

 

 

Long -Term Care Statute (24-A MRSA §§ 5071-5082)

 

Identify Policy Page and Provision OR Use Space to Explain if Requirement is Inapplicable

Are the following requirements of Chapter 68-A of Title 24-A of the Maine Insurance Code met?

 

 

*§ 5074(2)(A-G): Specifies the detailed content for the outline of coverage.

 

 

* § 5074(4): Policy summary for life policy containing LTCI provisions.

 

 

 

* § 5074(5): Requirements for LTC certificate of coverage issued under group policy.

 

 

 

* § 5075(1)(A): Prohibition against cancelling, nonrenewing, or otherwise terminating the policy based on age or deteriorating mental or physical health.

* § 5075(1)(B): Prohibition against establishing a new waiting period in the event that existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder. 

§ 5075(1)(C): Prohibition against limiting coverage to skilled nursing care or providing more coverage for skilled nursing than for other levels of care rendered in a skilled care facility.

 

 

 

* § 5075(2): Defines the maximum extent of an allowed preexisting condition limit.

 

 

 

* § 5075(3): Prohibits making eligibility for benefits conditional on a prior hospitalization requirement, on receipt of a higher level of care, or prior institutional care.

 

 

* § 5075(4): Requires disclosure on face page or attached to policy that insured has a 30-day free look period as of the policy delivery date.

 

 

* § 5076: Requires disclosure of phased incontestability periods leading, after two years, to no contestability unless the insured knowingly and intentionally misrepresented relevant facts.

 

 

* § 5077(1): Mandatory contingent nonforfeiture benefits if offer of nonforfeiture benefit is declined.

 

 

 

24-A MRSA §2185

 

* § 2185:  Calculation of health benefits must be based on insurer’s actual cost.

 

 

Maine Bureau of Insurance Rule Chapter 425

 

Are the following requirements of Maine Bureau of Insurance Rule 425 met?

 

 

§ 5: Extensive list of definitions which must appear in policy/certificate of coverage.

 

 

* § 6(B): Limited permitted exclusions from covered benefits.

 

 

* § 6(C):  Required disclosure that benefits may continue after policy terminates if insured was institutionalized before termination and remains institutionalized.

 

 

* § 6(D):  Mandatory continuation of coverage or conversion privilege to individual coverage must be disclosed in group policy/certificate of coverage.

 

 

* § 6(E): Relating to discontinuance and replacement of policies.

 

 

 

§ 6(G): Allows electronic signatures of individual insureds in employer, trade union and trustee group policies.

 

 

§ 6(H): Discloses right of certificateholder to a copy of the group policy. Requires disclosure in every certificate that if there is inconsistency between certificate and policy, the policy controls.

 

 

* § 7(A): Prevention of unintentional lapse: third party notice of cancellation and reinstatement for cognitive impairment or functional incapacity. See also Rule 580.

 

 

* § 7(B): Describes insured’s opportunity to reinstate as of right upon proof made within five months of lapse that the failure to pay premium was caused by cognitive impairment or functional incapacity.

 

 

 

* §§ 8(A) & 6(A): Policy disclosures: The first page of the policy must contain the renewability provision, which must specify that the policy is ‘guaranteed renewable’ or that it is ‘noncancelable,’ and explain what the term means.

 

 

* § 8(B): Policy disclosures: riders/endorsements added to an individual policy after the date of issue require signed acceptance by insured.*

 

 

* § 8(C): Policy disclosures: payment of benefits.

 

 

* § 8(D): Policy disclosures regarding limitations.

 

 

* § 8(E): Policy disclosures: for other limitations or conditions on eligibility for benefits.

 

 

* § 8(F); 24-A M.R.S.A. § 5074(3): The first page of the policy must state whether or not the policy is intended to be tax qualified under federal and Maine law. (Partnership policies are required to be tax qualified.)

 

 

* § 9: Requires the insurer to disclose at the time of application that premiums may be increased, and a history of premium increases for the policy or similar policies occurring in the last 10 years in Maine or any other state. The insurer must obtain the applicant’s signed acknowledgement of receiving this information.  Insurer must provide written notice of an upcoming rate increase to all policyholders and certificate holders at least 60 days before the effective date.

 

 

* § 11: Prohibition against post –claims underwriting.  Requires two conspicuous cautionary notices to applicant regarding the truthfulness and completeness of answers to medical questions, and warns of remedies available to insurer when applicant fails to heed the notices.

 

 

* § 12(A): Prohibits insurer from excluding or limiting home care or community care benefits by imposing any of nine unlawful burdens on insured as condition to such benefits:

  • insured would need care in skilled nursing facility if home care services were not provided;
  • insured must first or concurrently receive nursing or therapeutic services, or both, in a home, community or institutional services;
  • limiting eligible services to those rendered by registered or licensed practical nurses;
  • requiring a nurse or therapist to provide services that a licensed home care worker is competent to provide within his or her licensure;
  • excluding benefits for personal care services provided by a home health aide;
  • requiring that home care be at a licensure level greater than necessitated by the eligible service;
  • requiring the presence of an acute condition before home care benefits will be paid;
  • limiting benefits to only those services a Medicare-certified provider or agency renders;
  • excluding all benefits for adult day care services.

 

 

* § 12(B) & (C): Mandates a minimum benefit level for home care and community care services to have a dollar equivalent of at least 50% of one year of covered nursing home benefits.

Home health care coverage may be applied to the non-residential home health care benefits provided in the policy/certificate when determining maximum coverage under the policy or certificate.

 

 

§ 13(A): Requirements for optional inflation protection benefit at compounded annual rate of at least 5%, or specified alternative provisions.

 

 

§ 13(D): The outline of coverage must contain a graphic comparison, covering at least 20 years into the future, showing the amount of benefits with the inflation protection contrasted with the amount of benefits without the inflation protection.

 

 

* § 14: Application must include specific questions to determine whether the insured has another long-term care policy/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.  If the sale involves replacement of a current policy, Appendix A notice is required. 

 

 

* § 15: Pre-existing condition exclusions and probationary periods must be waived in replacement plans to the extent that they exceed the provisions of the prior plan.

 

 

* § 22(A): Additional marketing disclosure requirements.

 

     § 25: Policy or certificate must state that the insured is entitled to reduce coverage and lower the premium by either reducing the maximum benefit, or the daily, weekly or monthly benefit amount.  Other reduction options may be offered.  A description of how coverage may be reduced, and the process for requesting and implementing the reduction must be included. If the policy or certificate is about to lapse, the insurer must provide a written reminder of the right to reduce coverage and premiums.

 

 

§ 26(B), (D), (E): Requirements for optional nonforfeiture benefits.

 

 

* § 26(C), (D), (E): Requirements for mandatory contingent nonforfeiture benefits if the policyholder declines the offer of a nonforfeiture provision.

 

 

* § 29: Relating to standard format outline of coverage. Reiterates the insurer’s statutory duty to deliver an outline of coverage on first solicitation of prospective applicants, with the consumer’s signed acknowledgement of receipt and the producer’s signed representation of the delivery, with a cross reference to the acknowledgement form in Appendix G. Also reiterates the statute’s content requirements for the outline.

 

 

* § 30: Relating to requirement to deliver shopper’s guide.

 

 

 

Marketing Practices and Reporting Requirements:

Insurers must certify their compliance with the following requirements:

 

* 24-A M.R.S.A. § 5075(5): Reporting on accelerated death benefits.

 

* 24-A M.R.S.A. § 5077(1): Mandated offer of nonforfeiture benefit.

 

* Rule 425, § 16: Reporting on lapses, replacements, and claim denials.

 

* Rule 425, § 21: Filing of advertising materials.

 

* Rule 425, § 23, Development and use of suitability standards.

 

* To the extent that any disclosure requirements listed in other sections of this checklist are not satisfied by the provisions of this form, documents complying with the requirements are delivered to all consumers as required, and those documents have been filed with and approved by the Superintendent to the extent required.

 

 

 

 

Inflation Protection

 

 

Rule 425 § 13: Certification that all policyholders or certificate holders are offered a 5% compound inflation benefit or alternative inflation protection complying with Section 13.

 

 

*Partnership Policies Only:  Indicate which level of inflation protection is provided by the form(s).  If different forms or riders in this filing provide different levels of inflation protection, specify which form numbers fall within each category:

 

* (1):  Provides inflation protection at least equal to the change in the consumer price index (CPI-U), or compounded at an annual rate of at least 3%: May be offered to all ages.

 

 

* (2):  Provides inflation protection based on simple interest at an annual rate of at least 3%: Will be offered as a Partnership Policy only to consumers over age 60.

 

 

* (3): Does not provide inflation protection meeting the standards of Category (1) or Category (2): Will be offered as a Partnership Policy only to consumers over age 75.

 

* Required by federal law for Long-Term Care Partnership Policies

 

Certification

All Long-Term Care Policies in Maine are required to comply with the above provisions of the Maine Insurance Code and Rule 425. Policies offered as Long-Term Care Partnership policies must also provide inflation protection benefits to the extent required by federal law. Please complete the following:

I hereby certify that the answers, accompanying documents, and other information set forth herein for certification of the listed policy form or forms are to the best of my knowledge and belief, true, correct, and complete.  I understand that false, inaccurate or incomplete information on this form or accompanying documents may result in disapproval of listed policies for use in Maine and other administrative sanctions.
 
_________________________                      ___________________________________________
Date                                                                Signature

Contact Information:

Name of Certifying Officer:___________________________________

Title of Certifying Officer:     ____________________________________

Name of Company Contact
(If other than certifying officer): ________________________________

Phone Number:                       ____________________________________
 
Fax Number:               ____________________________________

E-Mail Address:                      ____________________________________

Mailing Address:                    ____________________________________

 


APPENDIX

 

[Company Letterhead]

IMPORTANT NOTICE REGARDING YOUR POLICY’S

LONG-TERM CARE INSURANCE PARTNERSHIP STATUS

 

(Please Keep This Notice with Your Policy or Certificate)

 

Policy Number ____________

Insured’s Name_______________

 

The Maine Long-Term Care Partnership Program is a partnership between Maine and private insurers offering long-term care insurance policies.  The Maine Long-Term Care Partnership Program became effective on July 1, 2009, and is provided in accordance with the federal Deficit Reduction Act of 2005 (P.L. 109-171).

Notice of Partnership Policy Status.  This Notice verifies that the long-term care insurance policy or certificate that you have purchased is intended to qualify under the Maine Long-Term Care Partnership Program as of the policy’s or certificate’s effective date.  This Notice explains the valuable MaineCare (Medicaid) asset protection that you may receive from purchasing a Partnership Policy.  The purchase of a Partnership Policy does not automatically qualify you for MaineCare.

MaineCare Asset Protection.  Long-term care insurance is an important tool that helps individuals prepare for future long-term care needs.  Partnership Policies provide an additional level of protection.  In particular, such policies permit individuals to protect additional assets from spend-down requirements under the MaineCare program if assistance under this program is ever needed and you otherwise qualify for MaineCare.

Specifically, when your assets are calculated for purposes of the eligibility and recovery provisions of the MaineCare program, MaineCare will disregard an additional amount of assets that is equal to the amount of insurance benefits you have received from your Partnership Policy.

For example, if you receive $200,000 of insurance benefits from your Partnership Policy, you generally would be able to retain $200,000 of assets above and beyond the amount of assets normally permitted for MaineCare eligibility.  Other MaineCare eligibility requirements regarding assets and income must still be met.  Medicaid eligibility requirements may vary from one state to another and may change over time.

Additional Consumer Protections.  In addition to providing MaineCare asset protection, your Partnership Policy has other important features.  Under the rules governing the Maine Long-Term Care Partnership Program, your Partnership Policy must be a qualified long-term care insurance contract under federal tax law, and as such, the insurance benefits you receive from the policy generally will be subject to beneficial income tax treatment.  (Please note that these tax benefits are not exclusive to Partnership Policies.  A policy can be a qualified long-term care insurance contract under federal tax law even if it is not a Partnership Policy.)  In order to qualify for the Partnership Program, your policy must also contain certain inflation protections if sold to you under age 76, with stronger protections required if you are under age 61.

What Could Disqualify Your Policy as a Partnership Policy.  If you make any changes to your policy or certificate, such changes could affect whether your policy or certificate continues to qualify as a Partnership Policy.  Before you make any changes, you should consult with the issuer of your policy to determine the effect of a 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 would not receive Medicaid asset protection in that state.  Also, changes in federal or state law could affect the Medicaid asset protection available with respect to your Partnership Policy.

Additional Information.  If you would like further information about the MaineCare asset protection provided by your Partnership Policy, please contact the Maine Department of Health and Human Services at (207) 287-3707 or visit their website at http://www.maine.gov/dhhs.  If you would like further information about the Maine Long-Term Care Partnership Program, please call the Maine Bureau of Insurance at (800) 300-5000 (in state) or (207) 624- 8458 or visit their website at http://www.maine.gov/pfr/insurance.

 

Last Updated: August 22, 2012