. The terms "guaranteed renewable" or "noncancelable"
shall be used in any long-term care insurance policy along with a disclosure,
as required by Section
, defining or explaining the terms.
(1) No policy shall contain any renewal
provision other than "guaranteed renewable" or "noncancelable."
(2) The term "guaranteed renewable" may be
used only if the insured has the right to continue the insurance in force by
the timely payment of premiums and if the insurer (a) has no unilateral
contractual right to change any policy provision while the insurance is in
force or (b) has no right to decline renewal, except on prior approval from the
superintendent to a rate change on a class basis that applies statewide. The
definition of "class" may not be based on health status or claims
(3) The term
"noncancelable" may be used only if the insured has the right to continue the
policy in force by the timely payment of premiums and the insurer has no
unilateral right to change any policy provision or the premium rate.
(4) The term "level premium" may be used only
when the insurer does not have the right to change the premium.
. A policy may not be issued as long-term care insurance if
the policy excludes or limits coverage by the type of illness, medical
condition or accident or the kind of treatment, except as follows:
(1) A preexisting condition or disease, which
shall be defined and covered as required under
(2) Mental or nervous disorders; however,
there shall be no exclusion or limitation for any disorder or disease, such as
Alzheimer's Disease, which demonstrably is the result of an organic
(3) Alcoholism and drug
condition or treatment arising from:
or act of war (whether declared or undeclared);
(b) Participation in a felony, riot or
(c) Service in the
armed forces or units auxiliary thereto;
(d) Suicide, attempted suicide or any
intentionally self-inflicted injury; or
(e) Aviation(this exclusion applies only to
non-fare paying passengers).
(5) Treatment in a government facility
(unless otherwise required by law); services for which benefits are available
under Medicare or other governmental program (except Medicaid); any federal or
state workers compensation, employer liability or occupational disease law; any
vehicle no-fault law; services provided to the insured by a person in the
insured's immediate family; and services for which usually no charge is made in
the absence of insurance coverage.
(6) Expenses for services or items paid under
another long-term care insurance or health insurance policy;
(7) In the case of a qualified long-term care
insurance contract, expenses for services or items to the extent that the
expenses are reimbursable under Title XVIII of the Social Security Act or would
be so reimbursable but for the application of a deductible or coinsurance
This Section is not intended to prevent
any exclusion or limitation based on the type of provider. However, no long
term care issuer may deny a claim because services are provided in a state
other than the state of policy issued under the following conditions:
(i) When the state other than the state of
policy issue does not have the provider licensing, certification or
registration required in the policy, but where the provider satisfies the
policy requirements outlined for providers in lieu of licensure, certification
or registration; or
(ii) When the
state other than the state of policy issue licenses, certifies or registers the
provider under another name.
(b) For purposes of this section, "state of
policy issue" means the state in which the individual policy or certificate was
This subsection is not intended to prohibit territorial limitations.
Benefits. Termination of insurance shall be without prejudice to any
benefit payable for institutionalization if the institutionalization began
while the insurance was in force and continues without interruption after
termination. The extension of benefits beyond the date of termination may be
limited to the duration of the benefit period, if any, or to payment of the
maximum benefits, and also may be made subject to any waiting period or other
applicable policy provision.
Continuation and Conversion of Group Coverage
(1) Every group long-term care insurance
policy or rider shall contain a provision for continuation or conversion of the
group coverage to individual coverage.
(2) "Continuation of coverage" means a
provision that maintains coverage under the group policy that would otherwise
terminate and under which maintenance of coverage is subject only to the timely
payment of premiums. Group policies that restrict payment of benefits or
services, or that contain incentives for the insured to use certain health care
providers or facilities, may provide continuation of coverage with benefits
substantially equivalent to benefits under the group policy. The superintendent
may make a determination as to the substantial equivalency of benefits, taking
into consideration any difference between managed care and non-managed care
plans, including such factors as provider system arrangements, availability of
services, benefit levels and administrative complexity.
(3) "Conversion of coverage" means a policy
provision entitling an insured, without establishing insurability, to have the
group insurer issue a converted (i.e., an individual) policy
upon termination of the group coverage for any reason, including discontinuance
of the policy in its entirety or with respect to an insured class. The right to
conversion may be subject to the condition that the insured be covered under
the group policy (or in combination with a group policy it replaced)
continuously for at least six months prior to the termination.
(4) "Converted policy" means an individual
policy containing benefits identical to (or benefits the superintendent
determines to be substantially equivalent to), or in excess of, the group
policy from which conversion occurs. If the converted policy restricts benefits
or services, or contains incentives for the insured to use certain health care
providers or facilities, the superintendent may consider, in determining
substantial equivalency, any difference between managed care and non-managed
care plans, including such factors as provider system arrangements,
availability of services, benefit levels and administrative complexity. There
shall be credit for that portion of the waiting period satisfied, except with
respect to an increase in benefits the insured voluntarily selects.
(5) The insured shall apply in writing for
conversion in a manner the insurer directs and shall pay the first premium, if
it becomes due, no later than 31 days after termination of the group policy.
The converted policy shall be issued effective on the day following the
termination of coverage under the group policy, and shall be renewable
(6) The premium for the
individual policy shall be calculated based on the insurer's age at the time of
inception of coverage under the group policy unless the group policy from which
conversion is made replaced previous group coverage. When the terminated group
coverage replaced other group coverage, the premium for the individual policy
shall be calculated on the basis of the insured's age at the inception of
coverage under the first group policy.
Continued or converted coverage is
mandatory for the insurer, except when:
Termination of the group coverage was the result of failure to timely pay the
premium or contribution; or
terminated coverage is replaced no later than 31 days after the termination by
new group insurance, which begins no later than the day after the date of
termination; the new group policy provides benefits identical (or substantially
equivalent, as the superintendent may determine) to the terminated coverage;
and the premium is calculated as described in Section
Notwithstanding any contrary provision in
, an individual policy issued
pursuant to conversion may contain a reduction of benefits provision if the
insured has another long-term care policy which pays benefits based on incurred
expenses. The reduction of benefits may occur if the additional coverage, when
combined with the benefits under the converted policy, exceeds 100% of incurred
expenses. The insurer may enforce a reduction of benefits provision only if the
converted policy requires a reduction or refund of premium reflecting the
(9) The converted
policy may provide that its benefits together with the benefits under the
terminated group policy shall not exceed benefits payable under the group
coverage, had it remained in force.
Notwithstanding any provision of Section
, an insured whose eligibility for
group coverage is based on his/her relationship to another person, shall be
entitled to a continuation of the group policy if the qualifying relationship
ended because of death or dissolution of marriage.
For the purposes of Section
, a managed-care plan is a health
care or assisted living plan designed to coordinate patient care or to control
costs through utilization review, case management or use of provider
Discontinuance and Replacement
. If a group policy is replaced by
another group policy issued to the same policyholder, the successor insurer
shall offer long-term care coverage to all persons insured, as of the
termination date, under the previous policy. Coverage and premiums under the
(1) Shall not result in an
exclusion for any preexisting condition for which there would be coverage under
the replaced policy; and
not vary or depend on the insured's health or disability status, claim
experience or prior use of long-term care services.
The premium charged to an insured shall
not increase because of either:
increasing age of the insured at ages beyond 65; or
(b) The duration the insured has been covered
under the policy.
The purchase of additional coverage shall not be considered a premium rate
increase for the purpose of the calculation required by Section
, the portion of the premium
attributable to the additional coverage shall be added to and considered part
of the initial annual premium.
A reduction in benefits shall not be considered a premium change, but, for the
purpose of the calculation under Section
, the initial annual premium shall
be based on the reduced benefits.
In the case of an employee group as
, a labor union groups as defined
, or a trustee groups as defined in
, any requirement that an insurer
or producer obtain the insured's signature shall be deemed satisfied if:
(a) The insurer, producer or policyholder
receives the insured's consent by telephonic or electronic enrollment. A
verification of enrollment information shall be provided to the
(b) The telephonic or
electronic enrollment provides necessary and reasonable safeguards to assure
the accuracy, retention and prompt retrieval of records; and
(c) Such enrollment contains reasonable and
necessary safeguards to protect the confidentiality of information which
2220 define as
(2) On request, the insurer shall make
available to the superintendent records that demonstrate the insurer's ability
to confirm enrollments and the amounts of coverage.
Certificate holder's Right to Copy
of Group Policy. Every group long-term care insurance policyholder shall
inform the certificate holder of the right, at his/her request to the insurer
and at no charge to the certificate holder, to receive a copy of the group
policy from the insurer or the policyholder. Every certificate also shall
disclose that if there is any inconsistency between the policy and the
certificate, the policy shall control.