reglab/statecodes huggingface dataset:
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.7.

10232.7. (a) An applicant for a long-term care insurance policy or a certificate, other than an applicant for a certificate issued under a group long-term care insurance policy issued to a group as described in subdivisions (a) and (b) of Section 10231.6, shall have the right to return the policy or certificate by first-class United States mail within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.
(b) The return of a policy or certificate shall void the policy or certificate from the beginning and the parties shall be in the same position as if no policy, certificate, or contract had been issued. All premiums paid and any policy fee paid for the policy shall be fully refunded directly to the applicant by the insurer within 30 days after the policy or certificate is returned.
(c) Notwithstanding Section 10276 or any other law, long-term care insurance policies or certificates to which this section applies shall have a notice prominently printed on the first page of the policy or certificate, or attached thereto, stating in substance the conditions described in subdivisions (a) and (b).
(Amended by Stats. 1989, Ch. 1273, Sec. 5.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.81.

10232.81. Every long-term care policy, certificate, or rider that purports to provide benefits of home care, community-based services, and residential care facility services under the California Partnership for Long-Term Care Program established by Section 22000 of the Welfare and Institutions Code shall provide at least the following:
(a) Care in a residential care facility.
(b) Home health care.
(c) Adult day care.
(d) Personal care.
(e) Homemaker services.
(f) Hospice services.
(g) Respite care.
(Amended by Stats. 2018, Ch. 565, Sec. 2. (SB 1248) Effective January 1, 2019.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.93.

10232.93. Every long-term care policy or certificate shall define the maximum lifetime benefit as a single dollar amount that may be used interchangeably for any home- and community-based services defined in Section 10232.9, assisted living benefit defined in Section 10232.92, or institutional care covered by the policy or certificate. There shall be no limit on any specific covered benefit except for a daily, weekly, or monthly limit set for home- and community-based care and for assisted living care, and for the limits for institutional care. Nothing in this section shall be construed as prohibiting limitations for reimbursement of actual expenses and incurred expenses up to daily, weekly, and monthly limits.
(Added by Stats. 1997, Ch. 699, Sec. 6. Effective October 6, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.95.

10232.95. Every long-term care policy or certificate that provides reimbursement for care in a nursing facility shall cover and reimburse for per diem expenses, as well as the costs of ancillary supplies and services, up to but not to exceed the maximum lifetime daily facility benefit of the policy or certificate.
(Added by Stats. 1997, Ch. 699, Sec. 6.3. Effective October 6, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.96.

10232.96. When a policy or certificate holder of an insurance contract issued prior to December 31, 1996, requests a material modification to the contract as defined by federal law or regulations, the insurer, prior to approving such a request, shall provide written notice to the policy or certificate holder that the contract change requested may constitute a material modification that jeopardizes the federal tax status of the contract and appropriate tax advice should therefore be sought.
(Added by Stats. 1997, Ch. 699, Sec. 6.5. Effective October 6, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10232.97.

10232.97. In every long-term care policy or certificate that covers care in a nursing facility, the threshold establishing eligibility for nursing facility care shall be no more restrictive than a provision that the insured will qualify if either one of two criteria are met:
(a) Impairment in two activities of daily living.
(b) Impairment in cognitive ability.
(Added by Stats. 1999, Ch. 947, Sec. 7. Effective January 1, 2000.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.

10233. Precedent to the payment of benefits for any care covered by the terms of the policy, any insurer offering long-term care insurance as described in Section 10231.2 may obtain a written declaration by a physician, independent needs assessment agency, or any other source of independent judgment suitable to the insurer that services are necessary.
(Added by Stats. 1989, Ch. 1273, Sec. 7.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.2.

10233.2. Long-term care insurance may not:
(a) Be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder.
(b) Contain a provision establishing a new waiting period in the event existing coverage is converted to, or replaced by, a new or other form within the same insurer, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder.
(c) Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.
(d) Provide for payment of benefits based on a standard described as “usual and customary,” “reasonable and customary,” or words of similar import.
(e) Terminate a policy, certificate, or rider, or contain a provision that allows the premium for an in-force policy, certificate, or rider, to be increased due to the divorce of a policyholder or certificate holder.
(f) Include an additional benefit for a service with a known market value other than the statutorily required home- and community-based service benefits in Section 10232.9, the assisted living benefit in Section 10232.92, or a nursing facility benefit, unless the additional benefit provides for the payment of at least five times the daily benefit and the dollar value of the additional benefit is disclosed in the schedule page of the policy.
(Amended by Stats. 1999, Ch. 947, Sec. 8. Effective January 1, 2000.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.25.

10233.25. No long-term care policy or certificate that is issued, amended, renewed, or delivered on and after January 1, 2002, shall contain a provision that prohibits or restricts any health facilities’ compliance with the requirements of Section 1262.5 of the Health and Safety Code.
(Added by Stats. 2001, Ch. 691, Sec. 7. Effective January 1, 2002.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.3.

10233.3. If a policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions and probationary periods to the extent that similar exclusions have been satisfied under the original policy or certificate.
(Added by Stats. 1992, Ch. 1132, Sec. 14. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.4.

10233.4. No long-term care insurance benefits may be reduced because of out-of-pocket expenditures by the insured or on behalf of the insured by a family member of the insured or by any other individual.
(Added by Stats. 1989, Ch. 1273, Sec. 9.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.6.

10233.6. A certificate issued pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery in this state, shall include all of the following:
(a) A description of the principal benefits and coverage provided in the policy.
(b) A statement of the principal exclusions, reductions, and limitations contained in the policy.
(c) A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premiums.
(d) A statement that the group master policy determines governing contractual provisions.
(e) An explanation of the insured’s rights regarding continuation, conversion, and replacement.
(Amended by Stats. 1992, Ch. 1132, Sec. 16. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.7.

10233.7. No policy may be advertised, marketed, or offered as long-term care or nursing home insurance unless it complies with this chapter.
(Added by Stats. 1989, Ch. 1273, Sec. 12.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - General Provisions › Section 10233.8.

10233.8. (a) A long-term care insurance policy or certificate issued, amended, renewed, or delivered on or after January 1, 2020, shall not do any of the following based solely and without any additional actuarial risks upon the status of a person as a living organ donor:
(1) Refuse to insure, or refuse to continue to insure, the person under a long-term care insurance policy or certificate.
(2) Limit the amount, extent, or kind of coverage available to the person under a long-term care insurance policy or certificate.
(3) Charge the person a different rate for the same coverage under a long-term care insurance policy or certificate.
(4) Otherwise discriminate in the offering, issuance, cancellation, amount of coverage, price, or any other condition of a long-term care insurance policy or certificate for the person.
(b) With respect to any health condition other than being a living organ donor, a person who is a living organ donor shall be subject to the same standards of sound actuarial principles or actual or reasonably anticipated experience as persons who are not living organ donors.
(c) For purposes of this section, “living organ donor” means an individual who has donated all or part of an organ and is not deceased.
(Added by Stats. 2019, Ch. 316, Sec. 5. (AB 1223) Effective January 1, 2020.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.

10234. The commissioner shall, as required by this chapter, or from time to time as conditions warrant, pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, adopt reasonable regulations, and amendments and additions thereto, as are necessary to administer this chapter.
(Added by Stats. 1989, Ch. 1273, Sec. 15.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.2.

10234.2. (a) In addition to all other powers and remedies vested in the commissioner by law, the commissioner shall have administrative authority to assess the penalties prescribed in this article for violation of any provision in this chapter against insurers, brokers, agents, and other entities which have been determined by the commissioner to be engaged in the business of insurance.
(b) Upon a showing of a violation of this chapter in any civil action, a court may also assess the penalties prescribed in this article. The court shall award reasonable attorney’s fees and costs to a prevailing plaintiff who establishes a violation of this chapter.
(c) Actions for injunctive relief, penalties prescribed in this article, damages, restitution, and all other remedies in law or equity, may be brought in superior court by the Attorney General, a district attorney, or city attorney on behalf of the people of the State of California for violation of any provision in this chapter. The court shall award reasonable attorney’s fees and costs to a prevailing plaintiff who establishes a violation of this chapter.
(Added by Stats. 1992, Ch. 1132, Sec. 18. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.3.

10234.3. (a) Any broker, agent, or other entity determined by the commissioner to engage in the business of insurance, other than an insurer, who violates this chapter is liable for an administrative penalty of not less than two hundred fifty dollars ($250) for each first violation. The penalty for committing a subsequent or a knowing violation of this chapter shall be not less than one thousand dollars ($1,000) and not more than twenty-five thousand dollars ($25,000) for each violation. The penalty for inappropriate replacement of long-term care coverage shall be not more than five thousand dollars ($5,000) for each violation.
(b) Any insurer that violates this chapter is liable for an administrative penalty of not less than five thousand dollars ($5,000) for each first violation. The penalty for committing a subsequent or knowing violation shall be not less than ten thousand dollars ($10,000) for each violation. The penalty for violating this chapter in a manner indicating a general business practice shall reflect the magnitude of the violation against the public interest and shall be not less than ten thousand dollars ($10,000) and not more than five hundred thousand dollars ($500,000).
(c) Penalties shall be paid to the Insurance Fund.
(Added by Stats. 1992, Ch. 1132, Sec. 19. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.4.

10234.4. In addition to the assessment of penalties and other applicable remedies, the commissioner may take the following actions upon determination that a violation of this chapter, or a regulation adopted pursuant to this chapter, has occurred:
(a) Suspend or revoke the license of any broker, agent, or other producer licensed by the department.
(b) Suspend an insurer’s certificate of authority to transact disability insurance.
(c) Order any broker, agent, insurer, or other entity determined by the commissioner to be engaged in the business of insurance, to cease marketing in California a particular policy form of long-term care insurance, to cease marketing any long-term care insurance, or to take such actions as are necessary to comply with this chapter.
(Repealed and added by Stats. 1992, Ch. 1132, Sec. 21. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.5.

10234.5. (a) Any broker, agent, insurer, or other entity within the jurisdiction of the department who is charged with a violation of this chapter shall be afforded due process through proper notice and public hearing, if requested, before a penalty may be assessed under Section 10234.3, an order issued under Section 10234.4, or other remedy imposed by the commissioner.
(b) Written notice, served by registered mail, shall include:
(1) A summary of the facts establishing reasonable cause that a violation has occurred.
(2) Citation of the code section or other standard allegedly violated.
(3) A statement of the commissioner’s intent to assess a penalty including the amount of the penalty, or to seek another remedy.
(4) A statement of the respondent’s right to elect any of the following:
(A) To accept assessment of the penalty or other remedy as stated in the notice.
(B) To respond to the charge in writing, after which the commissioner may issue a final order or set a hearing.
(C) To request, within 10 days of receipt of the notice, a public hearing.
(c) If timely requested by the respondent or ordered by the commissioner, a public hearing before the Administrative Law Bureau of the department shall be held within 30 days after the notice is served. Within 20 days after the hearing, the administrative law judge shall issue findings of fact and a proposed order. The commissioner shall issue his or her final order or the proposed order shall become the final order of the commissioner within 30 working days after the hearing unless reconsideration is granted for good cause by the administrative law judge. If the notice issued to the respondent assessed a penalty of one hundred thousand dollars ($100,000) or more and the respondent has timely requested, the hearing shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, and the commissioner shall have all the powers granted therein.
(d) The final order of the commissioner may contain one or more of the remedies set forth in this article. The amount of any penalty assessed need not be limited to the amount stated in the notice to the respondent.
(e) In addition to the penalties set forth in this section and any other penalties provided by law, the commissioner may suspend an insurer’s certificate of authority under Section 704 or assess a penalty under Section 704.7 if the commissioner finds, after notice and hearing, that the insurer has violated this chapter or regulations adopted pursuant to this chapter or that the insurer has knowingly permitted any person or entity to do so.
(Repealed and added by Stats. 1992, Ch. 1132, Sec. 23. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3 - Administration and Enforcement › Section 10234.7.

10234.7. The commissioner’s annual report to the Legislature, as required by Section 10234.6, shall be compiled in consultation with a task force designated by the commissioner for this purpose, which shall include insurance industry representatives, other individuals deemed appropriate by the commissioner, and one or more representatives from each of the following:
(a) The Health Insurance Counseling and Advocacy Program.
(b) The California Health Policy and Data Advisory Commission.
The commissioner shall have the responsibility, in consultation with the task force, to develop analytic methods and to select indicators for evaluation of the impact of long-term care insurance on the public share of costs for long-term care.
(Added by Stats. 1989, Ch. 1273, Sec. 15.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.8.

10234.8. (a) With regard to long-term care insurance, all insurers, brokers, agents, and others engaged in the business of insurance owe a policyholder or a prospective policyholder a duty of honesty, and a duty of good faith and fair dealing.
(b) Conduct of an insurer, broker, or agent during the offer and sale of a policy previous to the purchase is relevant to any action alleging a breach of the duty of honesty, and a duty of good faith and fair dealing.
(Amended by Stats. 2000, Ch. 442, Sec. 4. Effective January 1, 2001.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.85.

10234.85. No insurer, broker, agent, or other person shall cause a policyholder to replace a long term care insurance policy unnecessarily. Nothing in this section shall be construed to allow an insurer, broker, agent, or other person to cause a policyholder to replace a long term care insurance policy that will result in a decrease in benefits and an increase in premium.
It shall be presumed that any third or greater policy sold to a policyholder in any 12-month period is unnecessary within the meaning of this section. This section shall not apply to those instances in which a policy is replaced solely for the purpose of consolidating policies with a single insurer.
(Added by Stats. 1989, Ch. 631, Sec. 1.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.86.

10234.86. (a) Every insurer shall maintain records for each agent of that agent’s amount of replacement sales as a percent of the agent’s total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent’s total annual sales.
(b) Every insurer shall report annually by June 30, the 10 percent of its agents in the state with the greatest percentage of lapses and replacements as measured by subdivision (a).
(c) Every insurer shall report annually by June 30, the number of lapsed policies as a percent of its total annual sales in the state, as a percent of its total number of policies in force in the state, and as a total number of each policy form in the state, as of the end of the preceding calendar year.
(d) Every insurer shall report annually by June 30, the number of replacement policies sold as a percent of its total annual sales in the state and as a percent of its total number of policies in force in the state as of the end of the preceding calendar year.
(e) Reported replacement and lapse rates do not alone constitute a violation of insurance laws or imply wrongdoing. The reports are for the purpose of reviewing more closely agent activities regarding the sale of long-term care insurance.
(Amended by Stats. 2011, Ch. 426, Sec. 7. (SB 712) Effective January 1, 2012.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.87.

10234.87. (a) If an insurer replaces a policy or certificate that it has previously issued, the insurer shall recognize past insured status by granting premium credits toward the premiums for the replacement policy or certificate. The premium credits shall equal five percent of the annual premium of the prior policy or certificate for each full year the prior policy or certificate was in force. The premium credit shall be applied toward all future premium payments for the replacement policy or certificate, but the cumulative credit allowed need not exceed 50 percent. No credit need be provided if a claim has been filed under the original policy or certificate.
(b) The cumulative credits allowed need not reduce the premium for the replacement policy or certificate to less than the premium of the original policy or certificate.
(c) This section shall not apply to life insurance policies that accelerate benefits for long-term care.
(Amended by Stats. 1998, Ch. 1067, Sec. 5. Effective January 1, 1999.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.9.

10234.9. (a) Every insurer providing long-term care coverage in California shall provide a copy of any advertisement intended for use in California to the commissioner for review at least 30 days before dissemination. The advertisement shall comply with all laws in California. In addition, the advertisement shall be retained by the insurer in accordance with Section 10508 for at least three years.
(b) An advertisement designed to produce leads must prominently disclose that “an insurance agent will contact you” if that is the case.
(c) An agent, broker, or other person who contacts a consumer as a result of receiving information generated by a cold lead device, shall immediately disclose that fact to the consumer.
(Repealed and added by Stats. 1992, Ch. 1132, Sec. 25. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 3.7 - Consumer Protection › Section 10234.97.

10234.97. (a) Any time long-term care coverage is replaced, the sales commission that is paid by the insurer and that represents the percentage of the sale normally paid for first year sales of long-term care policies or certificates shall be calculated based on the difference between the annual premium of the replacement coverage and that of the original coverage. If the premium on the replacement product is less than or equal to the premium for the product being replaced, the sales commission shall be limited to the percentage of sale normally paid for renewal of long-term care policies or certificates. Replacement shall be contingent upon the insurer’s declaration that the replacement policy materially improves the position of the insured, pursuant to Section 10235.16. This provision does not apply to replacement coverage which is group insurance as described in subdivision (a) of Section 10231.6.
(b)  For purposes of this section, “commission or other compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate including, but not limited to, bonuses, gifts, prizes, awards, and finder’s fees.
(c)  Every long-term care insurer shall file with the commissioner within six months of the effective date of this section, its commission structure or an explanation of the insurer’s compensation plan. Any amendments to the commission structure shall be filed with the commissioner before implementation.
(Amended by Stats. 1993, Ch. 316, Sec. 1. Effective August 30, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.

10235. Except as provided in Section 10235.95, this article applies to all long-term care insurance policies delivered or issued for delivery in this state on or after January 1, 1990.
(Amended by Stats. 2008, Ch. 171, Sec. 1. Effective January 1, 2009.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.2.

10235.2. No long-term care insurance policy delivered or issued for delivery in this state shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements:
(a) “Medicare” shall be defined as the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended, or Title I, Part I of Public Law 89-97, as enacted by the 89th Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof, or words of similar import.
(b) “Skilled nursing care,” “intermediate care,” “home health care,” and other services shall be defined in relation to the level of skill required, the nature of the care and the setting in which care is required to be delivered.
(c) All providers of services, including, but not limited to, skilled nursing facilities, intermediate care facilities, and home health agencies shall be defined in relation to the services and facilities required to be available and the licensure or degree status of those providing or supervising the services. The definition may require that the provider be appropriately licensed or certified.
(Amended by Stats. 1999, Ch. 947, Sec. 9.5. Effective January 1, 2000.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.8.

10235.8. No policy may be delivered or issued for delivery in this state as long-term care insurance if the policy limits or excludes coverage by type of illness, treatment, medical condition, or accident, except as to the following:
(a) Preexisting conditions or diseases.
(b) Alcoholism and drug addiction.
(c) Illness, treatment, or a medical condition arising out of any of the following:
(1) War or act of war, whether declared or undeclared.
(2) Participation in a felony, riot, or insurrection.
(3) Service in the Armed Forces or units auxiliary thereto.
(4) Suicide, whether or not the person had mental capacity to control what he or she was doing, attempted suicide, or intentionally self-inflicted injury.
(5) Aviation in the capacity of a non-fare-paying passenger.
(d) Treatment provided in a government facility, unless otherwise required by law, services for which benefits are available under Medicare or other governmental programs (except Medi-Cal or medicaid), state or federal workers’ compensation, employer’s liability or occupational disease law, or a 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.
(e) This section does not prohibit exclusions and limitations by type of provider or territorial limitations.
(Amended by Stats. 2014, Ch. 144, Sec. 45. (AB 1847) Effective January 1, 2015.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.9.

10235.9. (a) Every insurer shall report annually by June 30 the total number of claims denied by each class of business in the state and the number of these claims denied for failure to meet the waiting period or because of a preexisting condition as of the end of the preceding calendar year.
(b) The insurer shall provide every policyholder or certificate holder whose claim is denied a written notice within 40 days of the date of denial of the reasons for the denial and all information directly related to the denial. Insurers shall annually report to the department the number of denied claims.
(c) The department shall make available to the public, upon request, the denial rate of claims by insurer.
(Added by Stats. 1997, Ch. 699, Sec. 12. Effective October 6, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.9a.

10235.9a. For policies or certificates issued on or after January 1, 2017, that contain an alternate plan of care provision pursuant to Section 10231.3, if an insurer and insured cannot agree on the terms of an alternate plan of care, the insurer shall provide a written explanation to the policyholder or certificate holder as to the specific reason or reasons why the agreement cannot be reached. The insurer shall provide the written explanation within 60 days of the insurer’s determination that an agreement cannot be reached.
(Added by Stats. 2016, Ch. 589, Sec. 4. (SB 1091) Effective January 1, 2017.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.10.

10235.10. Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if that institutionalization began while the long-term care insurance was in force and continues without interruption after termination. This extension of benefits beyond the period the 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.
(Added by Stats. 1989, Ch. 767, Sec. 2.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.14.

10235.14. (a) Individual long-term care insurance policies shall contain a renewability provision. This provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly disclose the term of coverage for which the policy is initially issued, the terms and conditions under which the policy may be renewed, and whether or not the issuer has the right to change the premium. If this right exists, the policy provisions shall clearly and concisely describe each circumstance under which the premium may change.
(b) Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy, all riders or endorsements added to an individual long-term care insurance policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require signed acceptance by the individual insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the insured, unless the increased benefits or coverage are required by law. If a separate additional premium is charged for benefits provided in connection with riders or endorsements, that premium charge shall be set forth in the policy, rider, or endorsement.
(c) If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, those limitations shall appear as a separate paragraph of the policy or certificate and shall be labeled as “preexisting condition limitations.”
(d) A long-term care insurance policy or certificate containing any limitations or conditions for eligibility shall set forth in a separate paragraph of the policy or certificate a description of those limitations or conditions, including any required number of days of confinement, and shall label that paragraph “Limitations or Conditions on Eligibility for Benefits.”
(Amended by Stats. 1992, Ch. 1132, Sec. 31. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.17.

10235.17. For purposes of this chapter, the commissioner shall define inappropriate replacement of long-term care insurance in consultation with other interested parties.
(Added by Stats. 1992, Ch. 1132, Sec. 33. Effective January 1, 1993.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.18.

10235.18. (a) Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the applicant upon issuance of the policy or certificate. The required notice shall be provided in the following form:
“NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE
According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance coverage delivered herewith issued by (company name) Insurance Company. Your new coverage provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy or certificate. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new coverage.
(1) Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new coverage. This could result in denial or delay in payment of benefits under the new coverage, whereas a similar claim might have been payable under your present coverage.
(2) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy coverage. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
(3) (To be included only if the application is attached to the policy or certificate). If, after due consideration, you still wish to terminate your present coverage and replace it with new coverage, read the copy of the application attached to your new coverage and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (company name and address) within thirty (30) days if any information is not correct and complete, or if any past medical history has been left out of the application.
(Company Name)”
(b) For group coverage not subject to the 30-day return provision of Section 10232.7, the notice shall be modified to reflect the appropriate time period in which the policy may be returned and premium refunded.
(Added by Stats. 1989, Ch. 767, Sec. 2.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.20.

10235.20. The commissioner may waive a specific provision or provisions of this article with respect to a specific long-term care insurance policy or certificate upon making written findings specified in subdivisions (a), (b), and (c), as follows:
(a) The waiver would be in the best interest of the insureds.
(b) The underlying purposes of this article could not be effectively or efficiently achieved without the waiver.
(c) Any of the following:
(1) The waiver is necessary to the development of an innovative and reasonable approach for insuring long-term care.
(2) The policy or certificate is to be issued to residents of a life care or continuing care retirement community or some other residential community for the elderly and the waiver is reasonably related to the special needs or nature of such a community.
(3) The waiver is necessary to permit long-term care insurance to be sold as part of, or in conjunction with, another insurance product.
The commissioner may condition any waiver upon compliance with alternative requirements to achieve the purposes of this article.
(Added by Stats. 1989, Ch. 767, Sec. 2.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.30.

10235.30. (a) No insurer may deliver or issue for delivery a long-term care policy in this state unless the insurer offers at the time of application an option to purchase a shortened benefit period nonforfeiture benefit with the following features:
(1) Eligibility begins no later than after 10 years of premium payments.
(2) The lifetime maximum benefit is no less than the dollar equivalent of three months of care at the nursing facility per diem benefit contained in the policy or the amount of the premiums paid, whichever is greater.
(3) The same benefits covered in the policy and any riders at the time eligibility begins are payable for a qualifying claim.
(4) The lifetime maximum benefit may be reduced by the amount of any claims already paid.
(5) Cash back, extended term, and reduced paid-up forms of nonforfeiture benefits shall not be allowed.
(6) The lifetime maximum benefit amount increases proportionally with the number of years of premium payment.
(b) This section shall not apply to life insurance policies that accelerate benefits for long-term care.
(Amended by Stats. 1999, Ch. 947, Sec. 11. Effective January 1, 2000.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.35.

10235.35. (a) Notwithstanding any other law, the commissioner may require the administration by an insurer of the contingent benefit upon lapse, as described in Section 28 (A), (D) (3), (E), (F), (G), and (J) of the Long-Term Care Insurance Model Regulation promulgated by the National Association of Insurance Commissioners, as adopted in September 2014, as a condition of approval or acknowledgment of a rate adjustment for a block of business for which the contingent benefit upon lapse is not otherwise available.
(b) The insurer shall notify policyholders and certificate holders of the contingent benefit upon lapse when required by the commissioner in conjunction with the implementation of a rate adjustment. The commissioner may require an insurer who files for such a rate adjustment to allow policyholders and certificate holders to reduce coverage pursuant to Section 10235.50 to avoid an increase in the policy’s premium amount.
(c) The commissioner may also approve any other alternative mechanism filed by the insurer in lieu of the contingent benefit upon lapse.
(Amended by Stats. 2015, Ch. 348, Sec. 24. (AB 1515) Effective January 1, 2016.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.51.

10235.51. (a) Every policy or certificate shall include a provision that gives the insured the option to elect, no less frequently than on each anniversary date after the policy or certificate is issued, to pay an extra premium for one or more riders that increase coverage in any of the following ways:
(1) Increase the amount of the per diem benefits.
(2) Increase the lifetime maximum benefit.
(3) Increase the amount of both the nursing facility per diem benefit and the home- and community-based care benefits of a comprehensive long-term care insurance policy or certificate.
(b) The premiums for the riders to increase coverage may be based on the attained age of the insured. The premium for the original policy or certificate will not be changed and will continue to be based on the insured’s age when the original policy or certificate was issued.
(c) The insurer may require the insured to undergo new underwriting, in addition to the payment of an additional premium, to qualify for the additional coverage. The insurer may restrict the age for issuance of additional coverage and restrict the aggregate amount of additional coverage an insured may acquire to the maximum age and coverage the insurer allows when issuing a new policy or certificate.
(Added by Stats. 1997, Ch. 699, Sec. 16. Effective October 6, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 2 - LIFE AND DISABILITY INSURANCE › CHAPTER 2.6 - Long-Term Care Insurance › ARTICLE 4 - Implementation › Section 10235.52.

10235.52. (a) Each policy shall contain a provision that, if the insurer develops new benefits or benefit eligibility or new policies with new benefits or benefit eligibility not included in the previously issued policy, the insurer shall grant current holders of its policies who are not in benefit or within the elimination period all of the following rights:
(1) The insurer shall notify the policyholder of the availability of the new benefits or benefit eligibility or new policy within 12 months of the date that the new policy series is made available for sale in this state. The insurer shall file the notice with the department at the same time as the new policy or rider.
(2) The insurer shall offer the policyholder new benefits or benefit eligibility in one of the following ways:
(A) By adding a rider to the existing policy and paying a separate premium for the new benefits or benefit eligibility based on the insured’s attained age. The premium for the existing policy shall remain unchanged based on the insured’s age at issuance.
(B) By replacing the existing policy or certificate in accordance with Section 10234.87.
(C) By replacing the existing policy or certificate with a new policy or certificate, in which case consideration for past insured status shall be recognized by setting the premium for the replacement policy or certificate at the issue age of the policy or certificate being replaced.
(b) The insured may be required to undergo new underwriting, but the underwriting can be no more restrictive than if the policyholder or certificate holder were applying for a new policy or certificate.
(c) The insurer of a group policy as defined under subdivisions (a) to (c), inclusive, of Section 10231.6 shall offer the group policyholder the opportunity to have coverage for the new benefits and provisions extended to existing certificate holders, but the insurer is relieved of the obligations imposed by this section if the holder of the group policy declines the issuer’s offer.
(d) For purposes of this section, new benefits means coverage for new long-term care services or providers that are material in nature. New benefits that are material in nature do not include changes to policy structure, benefits, or provisions that are minor in nature. Changes that are minor in nature include, but are not limited to, changes in elimination periods, benefit periods, and benefit amounts.
(Amended by Stats. 2017, Ch. 561, Sec. 140. (AB 1516) Effective January 1, 2018.)