OF LABOR AND REGULATION
Source: 22 SDR 97, effective December 18, 1995; 28 SDR 157, effective May 19, 2002.
Outline of Coverage. Note: A slant mark indicates alternatives. Parentheses
indicate instructions or blanks to be filled in. The remaining language is
intended to be used verbatim.
caution statement referred to in § 20:06:21:28
must appear as follows in the outline of coverage:
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).
policy is an individual policy of insurance/a group policy which was issued in
(indicate the jurisdiction in which the group policy was issued).
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!
Federal tax consequences.
[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.
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.
under which the policy or certificate may be continued in force or
long-term care health insurance policies or certificates describe one of the
following permissible policy renewability provisions:)
and certificates that are guaranteed renewable shall contain the following
statement:) RENEWABILITY: THIS POLICY OR
CERTIFICATE IS GUARANTEED RENEWABLE. This means you have the right,
subject to the terms of your policy or 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.
and certificates that are noncancelable shall contain the following statement:)
RENEWABILITY: THIS POLICY OR CERTIFICATE IS
NONCANCELABLE. 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
group coverage, specifically describe continuation/conversion provisions
applicable to the certificate and group policy.)
waiver of premium provisions or state that there are no such provisions.)
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.]
under which the policy or certificate may be returned and premium refunded:
a brief description of the right to return/"freelook" provision of
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.)
is not Medicare supplement coverage. If you are eligible for Medicare, review
the Medicare Supplement Buyer's Guide available from the insurance company.
agents,) neither (insert company name) nor its agents represent Medicare, the
federal government, or any state government.
direct response,) (insert company name) is not representing Medicare, the
federal government, or any state government.
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.
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
provided by this policy:
covered services, related deductibles, waiting periods, elimination periods,
and benefit maximums.)
institutional benefits, by skill level.)
noninstitutional benefits, by skill level.)
additional benefit screens must also be explained in this section. A benefit
screen is a provision in a policy or certificate that an insured must meet to
qualify for benefits. If these screens differ for different benefits,
explanation of the screen 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 must be
specified. If activities of daily living (ADLs) and cognitive impairment are
used to measure an insured's need for long-term care, these qualifying criteria
or screens must be explained and described as part of the outline of coverage.)
and exclusions. (Describe the following:)
levels of care, e.g., unlicensed providers or care or treatment provided by a
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 subdivision (9) above.)
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
YOUR LONG-TERM CARE NEEDS.
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:
the benefit level will not increase over time;
automatic benefit adjustment provisions;
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;
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; and
whether there will be any additional premium charge imposed and how it is to be
disease and other organic brain disorders.
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
the total annual premium for the policy.)
the premium varies with an applicant's choice among benefit options, indicate
the portion of annual premium which corresponds to each benefit option.)
if medical underwriting is used.)
other important features.)
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.