justicedao/ipfs_state_laws huggingface dataset:
836-052-0500 Statutory Authority; Applicability (1) OAR 836-052-0500 to 836-052-0786 are adopted pursuant to the requirements and authority of ORS 731.244,742.003, 742.005, 742.023, 743.013, 743.655, 743.656 and 746.240. (2) Except as otherwise specifically provided, OAR 836-052-0500 to 836-052-0786 apply to all long term care insurance policies, including qualified long term care contracts and life insurance policies that accelerate benefits for long term care delivered or issued for delivery in this state by insurers, fraternal benefit societies, nonprofit health, hospital and medical service corporations, prepaid health plans, health maintenance organizations and all similar organizations. (3) OAR 836-052-0500 to 836-052-0786 do not apply to a provision in a life insurance policy, rider or endorsement that provides accelerated death benefits in a single lump-sum upon the occurrence of a single qualifying event as defined in ORS 743.154. (4) OAR 836-052-0500 to 836-052-0786 apply to policies having indemnity benefits that are triggered by activities of daily living and sold as disability income insurance if: (a) The benefits of the disability income policy are dependent upon or vary in amount based on the receipt of long-term care services; (b) The disability income policy is advertised, marketed or offered as insurance for long-term care services; or (c) Benefits under the policy may commence after the policyholder has reached normal retirement age for Social Security unless benefits are designed to replace lost income or pay for specific expenses other than long-term care services. Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.685 & 746.240 Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 ID 3-2005, f. & cert. ef. 3-1-05 ID 1-1996, f. & cert. ef. 1-12-96 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0508 Definitions For the purpose of OAR 836-052-0500 to 836-052-0790: (1) The following have the meanings given those terms in ORS 743.652: (a) “Applicant;” (b) “Benefit trigger;” (c) “Certificate;” (d) “Group long term care insurance;” (e) “Long term care insurance;” (f) “Policy;” and (g) “Qualified long term care insurance.” (2) The following definitions apply: (a) “Independent review organization” means an organization qualified under OAR 836-052-0768(5) that conducts independent reviews of long term care benefit trigger decisions. (b) “Licensed health care professional” means an individual qualified by education and experience in an appropriate field, to determine, by record review, an insured’s actual functional or cognitive impairment. (c) "Qualified actuary" means a member in good standing of the American Academy of Actuaries. (d) "Similar policy forms" means all of the long term care insurance policies and certificates issued by an insurer in the same long term care benefit classification as the policy form being considered. Certificates of groups that meet the definition of ORS 743.652(3)(a) are not considered similar to certificates or policies otherwise issued as long term care insurance, but are similar to other comparable certificates with the same long term care benefit classifications. Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.685 & 746.240, OL 2007 Ch. 9 & 9a Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: ID 3-2012, f. & cert. ef. 2-14-12 ID 10-2007, f. 12-3-07, cert. ef. 1-1-08
836-052-0586 Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies (1) A long-term care insurance policy, certificate or rider that provides benefits for home care services or community care services may not limit or exclude those benefits: (a) By requiring that the insured or claimant would need care in a skilled nursing facility if home care services were not provided; (b) By requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services, or either service or simultaneously receive both services, in a home, community, or institutional setting before home care services are covered; (c) By limiting eligible services to services provided by registered nurses or licensed practical nurses; (d) By requiring that a nurse or therapist provide services covered by the policy when the services can be provided by a home care aide or other licensed or certified home care worker acting within the scope of the licensure or certification; (e) By requiring that the insured or claimant have an acute condition before home care services are covered; (f) By excluding coverage for personal care services provided by a home care aide; (g) By requiring that the provision of home care services be at a level of certification or licensure greater than that required by the eligible service; (h) By limiting benefits to services provided by Medicare-certified agencies or providers; or (i) By excluding coverage for adult day care services. (2) A provision in a long-term care insurance policy, certificate or rider for home care or community care services shall provide total home care or community care coverage that is a dollar amount equivalent to at least one-half of one year’s coverage available for nursing home benefits under the policy, certificate or rider, at the time covered home care or community care services are being received. This requirement does not apply to policies, certificates or riders issued to residents of continuing care retirement communities. (3) Home care coverage may be applied to the nonhome care benefits provided in the policy, certificate or rider when determining maximum coverage under the terms of the policy, certificate or rider. Statutory/Other Authority: ORS 731, 742 & 743 Statutes/Other Implemented: ORS 743.655(1)(a) & 743.656 History: Renumbered from 836-052-0535, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0596 Standards for Covered Services This rule establishes standards for covered services for the purpose of payment of benefits pursuant to ORS 743.656. An insurer shall not define the covered services more restrictively than the following minimum standards, or similar standards found by the Director to be substantially as favorable to the consumer: (1) Nursing home services, when provided to the insured in this state, include services provided in or by a nursing home licensed under ORS 678.710 to 678.840. When provided to the insured outside this state, nursing home services include services provided in or by a nursing home in the other state. The nursing home must be licensed by the other state if so required by a similar licensing or other regulatory program; (2) Assisted living services, when provided to the insured in this state, include those services provided in a facility or by a person licensed or otherwise regulated by this state to provide assisted living services as that term is defined in OAR 411-056-0005. When the services are provided to the insured outside this state, the provider or providing facility must be licensed by the other state if so required by a similar licensing or other regulatory program; (3) Home care services, regardless of the state in which they are provided, include service provided in the insured’s own home rather than a facility such as an assisted living facility or adult foster care facility; (4) Adult foster care services, when provided to the insured in this state, include those services that are provided in an adult foster home pursuant to a license issued under ORS 443.705 to 443.825. When the services are provided to the insured outside this state, the provider or providing facility must be licensed by the other state if so required by a similar licensing or other regulatory program; and (5) Services through a residential care facility, when provided to the insured in this state, include those services provided in a facility or by a person licensed or otherwise regulated by this state to provide services through a residential care facility as that term is defined in ORS 443.400. When the services are provided to the insured outside this state, the provider or providing facility must be licensed by the other state if so required by a similar licensing or other regulatory program. Statutory/Other Authority: ORS 731.244 & 743.656 Statutes/Other Implemented: ORS 743.656 History: Renumbered from 836-052-0583, ID 3-2005, f. & cert. ef. 3-1-05 ID 9-1991, f. 12-24-91, cert. ef. 1-1-92
836-052-0606 Use and Definition of “Home” or Similar Wording A long-term care insurance policy that defines “home” or uses similar wording to refer to the residence of the insured shall define or use wording that means or refers to the principal place of residence for the insured, whether a private home, a foster home, congregate care or assisted living facility or other place in a community setting, other than a licensed nursing facility. Statutory/Other Authority: ORS 731, 742 & 743 Statutes/Other Implemented: ORS 743.655(1)(a) & 743.656 History: Renumbered from 836-052-0580, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0636 Reporting Requirements (1) Every insurer shall maintain records for each insurance producer of that insurance producer's amount of replacement sales as a percent of the insurance producer's total annual sales and the amount of lapses of long-term care insurance policies sold by the insurance producer as a percent of the insurance producer's total annual sales. (2) Reported replacement and lapse rates do not alone constitute a violation of insurance laws or necessarily imply wrongdoing. The reports are for the purpose of reviewing more closely agent activities regarding the sale of long-term care insurance. (3) Every insurer shall report to the director annually by June 30 the ten percent of its insurance producers with the greatest percentages of lapses and replacements as measured by section (1) of this rule using the form provided by the director on the Division of Financial Regulation website or a similar form and shall also include the following information in the annual report: (a) The number of lapsed policies as a percent of its total annual sales and as a percent of its total number of policies in force as of the end of the preceding calendar year. (b) The number of replacement policies sold as a percent of its total annual sales and as a percent of its total number of policies in force as of the preceding calendar year. (4) Every insurer shall report to the director annually by June 30, for qualified long-term care insurance contracts, the number of claims denied for each class of business, expressed as a percentage of claims denied using the form provided by the director on the Division of Financial Regulation website or a similar form. (5) An insurer shall file the reports required under this rule with the director. (6) As used in this rule: (a) "Claim" means, subject to subsection (b) of this section, a request for payment of benefits under an in force policy regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met; (b) "Denied" means the insurer refuses to pay a claim for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition; (c) "Policy" means only long term care insurance; and (d) "Report" means on a statewide basis. [ED. NOTE: Exhibits referenced are available from the agency.] Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 731.244, 743.655, 743.656, 746.240, 742.003, 742.005, 742.009, 743.010, 743.013, 743.650 & 743.653 History: ID 20-2024, minor correction filed 08/12/2024, effective 08/12/2024 ID 5-2015, f. 6-10-15, cert. ef. 1-1-16 ID 4-2011, f. & cert. ef. 2-10-11 ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 ID 3-2005, f. & cert. ef. 3-1-05
836-052-0639 Training for Insurance Producers (1) When the provider of a training course notifies an insurance producer that the insurance producer has successfully completed the training course and passed the examination, the insurance producer shall send the notice of completion as verification of the training to each insurer for which the insurance producer transacts or will transact long term care insurance in this state. The insurer shall approve or disapprove the verification as meeting the requirements of section 9, chapter 486, Oregon Laws 2007 and return the verification to the insurance producer. (2) An insurance producer shall submit the notice of completion of required training to the Director as approved by each insurer under section (2) of this rule when the insurance producer reports to the Director at license renewal regarding compliance with continuing education requirements. (3) A training course taken online or through self-study in satisfaction of the requirements of section 9, chapter 486, Oregon Laws 2007 (Enrolled SB 191) must include an examination indicating understanding of the topics covered in the course. An insurance producer does not satisfy the training requirement of section 9, chapter 486, Oregon Laws 2007 unless the individual passes the examination for the online or self-study training course with a score of not less than 70 percent. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: Sec. 9, Ch. 486 & OL 2007 (Enrolled SB 191) History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08
836-052-0646 Benefits Provided Through Advancement of Life Insurance Proceeds (1) When long term care benefits are provided through early payment of a portion of a life insurance policy death benefit, the insurer may make no more than a pro rata reduction in the life insurance policy cash value, based on the percentage of death benefits advanced. When the cash value is reduced in this manner, the insurer may apply no more of the payment to the reduction of any outstanding policy loans than this same pro rata percentage. (2) For each month in which a long term care benefit has been provided through early payment of a portion of a life insurance death benefit, the insurer shall provide a report to the policyholder showing the benefits paid during the month, the change in the life insurance policy cash value, loan balance and death benefit, and the amount of benefits remaining. Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: Renumbered from 836-052-0588, ID 3-2005, f. & cert. ef. 3-1-05 ID 1-1996, f. & cert. ef. 1-12-96
836-052-0656 Reserve Standards (1)(a) Each insurer shall use the following standards for determining policy reserves for long-term care insurance: When long-term care benefits are provided through the acceleration of benefits under a group or individual life insurance policy or a rider to such a policy, policy reserves for the benefits shall be determined in accordance with ORS 733.322. Claim reserves shall also be established in the case when the policy or rider is in claim status. (b) Reserves for policies and riders subject to this section shall be based on the multiple decrement model using all relevant decrements except for voluntary termination rates. Single decrement approximations are acceptable if the calculation produces essentially similar reserves, if the reserve is clearly more conservative or if the reserve is immaterial. The calculations may take into account the reduction in life insurance benefits due to the payment of long-term care benefits. However, in no event shall the reserves for the long-term care benefit and the life insurance benefit be less than the reserves for the life insurance benefit assuming no long-term care benefit. (c) In the development and calculation of reserves for long-term care insurance policies and riders subject to this section, an insurer shall consider the applicable policy and rider provisions, marketing methods, administrative procedures and all other considerations that affect projected claim costs, including but not limited to the following: (A) Definition of insured events; (B) Covered long-term care facilities; (C) Existence of home care and home care coverage. For purposes of this paragraph, "home" has the meaning provided in OAR 836-052-0606; (D) Definition of facilities; (E) Existence or absence of barriers to eligibility; (F) Premium waiver provisions; (G) Renewability; (H) Ability to raise premiums; (I) Marketing methods; (J) Underwriting procedures; (K) Claims adjustment procedures; (L) Waiting periods; (M) Maximum benefits; (N) Availability of eligible facilities; (O) Margins in claim costs; (P) Optional nature of benefit; (Q) Delay in eligibility for benefit; (R) Inflation protection provisions; and (S) Guaranteed insurability option. (2) For purposes of section (1) of this rule, an applicable valuation morbidity table shall be certified as appropriate as a statutory valuation table by a qualified actuary. (3) When long term care benefits are provided other than as in section (1) of this rule, reserves shall be determined in accordance with OAR 836-031-0200 to 836-031-0300. Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 Renumbered from 836-052-0545, ID 3-2005, f. & cert. ef. 3-1-05 ID 1-1996, f. & cert. ef. 1-12-96 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0686 Filing Requirements for Out-of-State Group Policies Each insurer providing group long-term care insurance benefits to a resident of this state under an exempt master group policy pursuant to ORS 731.486 issued outside of this state shall file, for informational purposes, a copy of the policy form filed for approval with the state of domicile of the insurer and any rider or certificate used in this state in accordance with the filing requirements and procedures applicable to group entities filing in this state. Statutory/Other Authority: ORS 731, 742 & 743 Statutes/Other Implemented: ORS 731.244 & 743.653 History: Renumbered from 836-052-0550, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0696 Filing Requirements for Advertising At the request of the Director, every insurer, health care service plan or other entity providing long-term care insurance or benefits in this state shall provide to the Director a copy of any long-term care insurance advertisement intended for use in this state, whether through the written, radio or television medium, for review or approval by the Director as authorized under ORS 742.009 and other state law. In addition, all advertisements shall be retained by the insurer, health care service plan or other entity for at least three years from the date the advertisement was first used. Each advertisement shall comply with all applicable laws and rules of this state. Statutory/Other Authority: ORS 731.244 & 742.009 Statutes/Other Implemented: ORS 742.009 & 743.655(1)(a) History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 ID 5-2006, f. 3-15-06, cert. ef. 3-20-06 ID 12-2005(Temp), f. & cert. ef. 10-3-05 thru 3-20-06 Renumbered from 836-052-0620, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0716 Disclosure Statement (1) An insurer offering long-term care insurance coverage in this state shall deliver a disclosure statement as provided in this rule to the insured under a long-term care insurance policy, rider or certificate or separately but at the same time as delivery of the policy, rider or certificate. (2) The disclosure statement must include the following matters: (a) A statement of the premium. The statement must give the total annual premium for the policy, rider or certificate and, if the premium varies with an applicant’s choice among benefits options, must indicate the portion of annual premium corresponding to each benefit option; (b) The terms of renewability. The terms used to describe renewability must be used in accordance with OAR 836-052-0526. The terms must be stated on the first page of the policy and must be one of the following, defined as follows: (A) A policy is “guaranteed renewable” when renewal cannot be declined by the insurer for any reason, but the insurer can revise rates on a class basis; (B) A policy is “noncancellable” if the insurer cannot decline renewal and cannot revise rates. (c) Initial and subsequent conditions of eligibility; (d) A statement of nonduplication of coverage provisions; (e) Coverage of dependents; (f) Preexisting conditions; (g) Termination of insurance; (h) Continuation or conversion of coverage; (i) Any probationary periods; (j) Limitations, exceptions and reductions; (k) Elimination periods; (l) Requirements for replacement; (m) Recurrent conditions; (n) Definitions of terms; (o) Option to apply for new benefits (3) The disclosure statement: (a) Must be printed in not less than twelve point type; (b) May not contain material of an advertising nature. (4) The disclosure statement must include the following statement: CAUTION: Issuance of this long-term care insurance (policy) (rider) (certificate) is based upon your answers to the questions on your application. (A copy of your (application) (enrollment form) is enclosed.) — OR — (You retained a copy of your (application) (enrollment form) when you applied.) If your answers are incorrect or untrue, the company may deny benefits or rescind your policy. (5) When long term care benefits are provided through early payment of a portion of a life insurance policy death benefit, the disclosure statement must include the following statements: (a) “NOTICE: The long term care benefits described here are provided as part of a life insurance policy. Your premiums pay for life insurance. Whenever long term care benefits are paid from this policy, the payments will reduce the available cash value and death benefit under the life insurance policy”; (b) A statement of disclosure regarding tax consequences, as described in OAR 836-052-0546(6). Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: Renumbered from 836-052-0605, ID 3-2005, f. & cert. ef. 3-1-05 ID 1-1996, f. & cert. ef. 1-12-96 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0736 Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates (1) If a long-term care insurance policy replaces another long-term care insurance policy, the replacing insurer shall waive any time periods applicable to preexisting conditions, waiting periods and probationary periods in the new long-term care insurance policy for similar benefits to the extent that similar exclusions have been satisfied under the original policy. (2) If a group long-term care policy is replaced by another group long-term care policy purchased by the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the old group policy on its date of termination. Statutory/Other Authority: ORS 731, 742 & 743 Statutes/Other Implemented: ORS 743.655(1)(a) History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 Renumbered from 836-052-0575, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91