Utah Admin. Code R590-285-5 - Policy Practices and Provisions
(1) Renewability. The terms "guaranteed
renewable" and "noncancellable" may not be used in any individual limited
long-term care insurance policy without further explanatory language in
accordance with the disclosure requirements of Section R590-285-7.
(a) A policy issued to an individual may not
contain renewal provisions other than "guaranteed renewable" or
"noncancellable."
(b) The term
"guaranteed renewable" may be used only when the insured has the right to
continue the limited long-term care insurance in force by the timely payment of
premiums and when the insurer has no unilateral right to make any change in any
provision of the policy or rider while the insurance is in force, and cannot
decline to renew, except that rates may be revised by the insurer on a class
basis.
(c) The term
"noncancellable" may be used only when the insured has the right to continue
the limited long-term care insurance in force by the timely payment of premiums
during which period the insurer has no right to unilaterally make any change in
any provision of the insurance or in the premium rate.
(d) The term "level premium" may only be used
when the insurer does not have the right to change the premium.
(2)
(a) Limitations and Exclusions. A policy may
not be delivered or issued for delivery in this state as limited long-term care
insurance if the policy limits or excludes coverage by type of illness,
treatment, medical condition, or accident, except as follows:
(i) alcoholism and drug addiction;
(ii) illness, treatment, or medical condition
arising out of:
(A) war or act of war, whether
declared or undeclared;
(B)
participation in a felony, riot, or insurrection, when the insured is a
voluntary participant;
(C) service
in the armed forces or units auxiliary thereto;
(D) suicide, sane or insane, attempted
suicide, or intentionally self-inflicted injury; or
(E) aviation, only to a non-fare-paying
passenger;
(iii) mental
or nervous disorders; however, this may not permit exclusion or limitation of
benefits on the basis of cognitive impairment ;
(iv) preexisting conditions or diseases;
and
(v) treatment provided in a
government facility, unless otherwise required by law, services for which
benefits are available under Medicare or other governmental program, except
Medicaid, any state or federal workers' compensation, employer's liability or
occupational disease law, or any motor vehicle no-fault law, services provided
by a member of the covered person's immediate family and services for which no
charge is normally made in the absence of insurance.
(b)
(i) This
Subsection R590-285-5(2), is not intended to prohibit exclusions and
limitations by type of provider. However, no limited 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:
(A) 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
(B) when the
state other than the state of policy issue licenses, certifies, or registers
the provider under another name.
(ii) For purposes of this subsection, "state
of policy issue" means the state in which the individual policy or certificate
was originally issued.
(iii) This
subsection is not intended to prohibit territorial limitations outside of the
United States.
(3) Extension of Benefits.
(a) Termination of limited long-term care
insurance shall be without prejudice to any benefits payable for
institutionalization if the institutionalization began while the limited
long-term care insurance was in force and continues without interruption after
termination.
(b) The extension of
benefits beyond the period the limited long-term care insurance was in force
may be limited to the duration of the benefit period, if any, or to payment of
the maximum benefits and may be subject to any policy waiting period, and all
other applicable provisions of the policy.
(4) Continuation or Conversion.
(a) Group limited long-term care insurance
issued in this state shall provide covered individuals with a basis for
continuation or conversion of coverage.
(b) For the purposes of this Subsection
R590-285-5(4):
(i) "a basis for continuation
of coverage" means a policy provision that maintains coverage under the
existing group policy when the coverage would otherwise terminate, and which is
subject only to the continued timely payment of premium when due. Group
policies that restrict provision of benefits and services to or contain
incentives to use certain providers or facilities may provide continuation
benefits that are substantially equivalent to the benefits of the existing
group policy. The commissioner shall make a determination as to the substantial
equivalency of benefits, and in doing so, shall take into consideration the
differences between managed care and non-managed care plans, including, but not
limited to, provider system arrangements, service availability, benefit levels,
and administrative complexity;
(ii) "a basis for conversion of coverage"
means a policy provision that an individual whose coverage under the group
policy would otherwise terminate or has been terminated for any reason,
including discontinuance of the group policy in its entirety or with respect to
an insured class, and who has been continuously insured under the group policy,
and any group policy which it replaced, for at least six months immediately
prior to termination, shall be entitled to the issuance of a converted policy
by the insurer under whose group policy he or she is covered, without evidence
of insurability; and
(iii)
"converted policy" means an individual policy of limited long-term care
insurance providing benefits identical to or benefits determined by the
commissioner to be substantially equivalent to or in excess of those provided
under the group policy from which conversion is made. Where the group policy
from which conversion is made restricts provision of benefits and services to,
or contains incentives to use certain providers or facilities, the
commissioner, in making a determination as to the substantial equivalency of
benefits, shall take into consideration the differences between managed care
and non-managed care plans, including, but not limited to, provider system
arrangements, service availability, benefit levels, and administrative
complexity.
(c) Written
application for the converted policy shall be made and the first premium due,
if any, shall be paid as directed by the insurer not later than 60 days after
termination of coverage under 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 annually.
(d) Unless the group policy from which
conversion is made replaced previous group coverage, the premium for the
converted policy shall be calculated on the basis of the insured's age at
inception of coverage under the group policy from which conversion is made.
Where the group policy from which conversion is made replaced previous group
coverage, the premium for the converted policy shall be calculated on the basis
of the insured's age at inception of coverage under the group policy
replaced.
(e) Continuation of
coverage or issuance of a converted policy shall be mandatory, except where:
(i) termination of group coverage resulted
from an individual's failure to make any required payment of premium or
contribution when due; or
(ii) the
terminating coverage is replaced not later than 31 days after termination, by
group coverage effective on the day following the termination of coverage:
(A) providing benefits identical to or
benefits determined by the commissioner to be substantially equivalent to or in
excess of those provided by the terminating coverage; and
(B) the premium for which is calculated in a
manner consistent with the requirements of Subsection
R590-285-5(4)(d).
(f) Notwithstanding any other provision of
this section, a converted policy issued to an individual who at the time of
conversion is covered by another limited long-term care insurance policy that
provides benefits on the basis of incurred expenses, may contain a provision
that results in a reduction of benefits payable if the benefits provided under
the additional coverage, together with the full benefits provided by the
converted policy, would result in payment of more than 100% of incurred
expenses. The provision shall only be included in the converted policy if the
converted policy also provides for a premium decrease or refund which reflects
the reduction in benefits payable.
(g) The converted policy may provide that the
benefits payable under the converted policy, together with the benefits payable
under the group policy from which conversion is made, may not exceed those that
would have been payable had the individual's coverage under the group policy
remained in force and effect.
(h)
Notwithstanding any other provision of this section, an insured individual
whose eligibility for group limited long-term care coverage is based upon his
or her relationship to another person shall be entitled to continuation of
coverage under the group policy upon termination of the qualifying relationship
by death or dissolution of marriage.
(5) Discontinuance and Replacement. If a
group limited long-term care policy is replaced by another group limited
long-term care policy issued to the same policyholder, the succeeding insurer
shall offer coverage to all persons covered under the previous group policy on
its date of termination. Coverage provided or offered to individuals by the
insurer and premiums charged to persons under the new group policy:
(a) may not result in an exclusion for
preexisting conditions that would have been covered under the group policy
being replaced; and
(b) may not
vary or otherwise depend on the individual's health or disability status, claim
experience or use of limited long-term care services.
(6) Premium Changes.
(a) The premium charged to an insured may not
increase due to either:
(i) the increasing age
of the insured at age 66 or older; or
(ii) the duration the insured has been
covered under the policy.
(b) The purchase of additional coverage may
not be considered a premium rate increase, but for purposes of the calculation
required under Section R590-285-22, the portion of the premium attributable to
the additional coverage shall be added to, and considered part of, the initial
annual premium.
(c) A reduction in
benefits may not be considered a premium change, but for purposes of the
calculation required under Section R590-285-22, the initial annual premium
shall be based on the reduced benefits.
(7) Electronic Enrollment for Group Policies.
(a) In the case of a group defined in
Subsection
31A-22-2002(3),
any requirement that a signature of an insured be obtained by an agent or
insurer shall be deemed satisfied if:
(i) the
consent is obtained by telephonic or electronic enrollment by the group
policyholder or insurer. A verification of enrollment information shall be
provided to the enrollee;
(ii) the
telephonic or electronic enrollment provides necessary and reasonable
safeguards to assure the accuracy, retention, and prompt retrieval of records;
and
(iii) the telephonic or
electronic enrollment provides necessary and reasonable safeguards to assure
that the confidentiality of individually identifiable information and
privileged information is maintained.
(b) The insurer shall make available, upon
request of the commissioner, records that will demonstrate the insurer's
ability to confirm enrollment and coverage amounts.
Notes
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