This section of the regulation implements, interprets and
makes specific, the provisions of
W.S.
26-38-105(k) in prescribing
a standard format and the content of an outline of coverage.
(a) The outline of coverage shall be a
free-standing document, using no smaller than ten point type.
(b) The outline of coverage shall contain no
material of an advertising nature.
(c) Text which is capitalized or underscored
in the standard format outline of coverage may be emphasized by other means
which provide prominence equivalent to such capitalization or
underscoring.
(d) Use of the text
and sequence of text of the standard format outline of coverage is mandatory,
unless otherwise specifically indicated.
(e) Format for outline of coverage:
[COMPANY NAME]
[ADDRESS - CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE OUTLINE
OF COVERAGE
[Policy Number of 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. 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.]
4. 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 agents] Neither [insert company
name] nor its agents 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.
5. 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.]
6. BENEFITS PROVIDED BY THIS POLICY.
(a) [Covered services, related deductible(s),
waiting periods, elimination periods and benefit maximums.]
(b) [Institutional benefits, by skill
level.]
(c) [Non-institutional
benefits, by skill level.]
[Any benefit screens must be explained in this section. 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 too must be specified. If activities of daily
living (ADLs) are used to measure an insured's need for long-term care, then
these qualifying criteria or screens must be explained.]
7. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a)
Preexisting conditions;
(b)
Non-eligible facilities/provider;
(c) Non-eligible levels of care (e.g.,
unlicensed providers, care or treatment provided by a family member,
etc.);
(d)
Exclusions/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 (6)
above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
YOUR LONG-TERM CARE NEEDS.
8. 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.]
9. TERMS UNDER WHICH THE POLICY (OR
CERTIFICATE) MAY BE CONTINUED IN FORCE OR DISCONTINUED.
[(a) Describe the policy renewability
provisions;
(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;
(d) State whether or
not the company has a right to change premium, and if such a right exists,
describe clearly and concisely each circumstance under which premium may
change.]
10. 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.]
11.
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.]
12. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is
used;
(b) Describe other important
features.]
