Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 10 - LONG-TERM CARE INSURANCE › Appendix J - Long-term Care Insurance Outline of Coverage

Current through Register Vol. 30, No. 28, July 12, 2024
[COMPANY NAME]
[ADDRESS - CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate
				  Number]
[Except for policies or certificates which are guaranteed
				  issue, the following caution statement, or language substantially similar,
				  shall 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. FEDERAL TAX CONSEQUENCES
This [POLICY] [CERTIFICATE] is intended to be a federally
				  tax-qualified long-term care insurance contract under Section 7702(B)(b) of the
				  Internal Revenue Code of 1986, as amended.
OR
Federal Tax Implications of this [POLICY] [CERTIFICATE]. This
				  [POLICY] [CERTIFICATE]. is not intended to be a federally tax-qualified
				  long-term care insurance contract under Section 7702(B)(b) of the Internal
				  Revenue Code of 1986, as amended. Benefits received under the [POLICY]
				  [CERTIFICATE] may be taxable as income.
4. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE
				  CONTINUED IN FORCE OR DISCONTINUED
(a) [For long-term care health insurance policies or
				  certificates describe one of the following permissible policy renewability
				  provisions:
(1) Policies and certificates that are guaranteed renewable
				  shall contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE]
				  IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of
				  your policy, [certificate] to continue this policy as long as you pay your
				  premiums on time. [Company Name] cannot change any of the terms of your policy
				  on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU
				  PAY.
(2) [Policies and certificates that are noncancellable shall
				  contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS
				  NONCANCELLABLE. This means that you have the right, subject to the terms of
				  your policy, to continue this policy as long as you pay your premiums on time.
				  [Company Name] cannot change any of the terms of your policy on its own and
				  cannot change the premium you currently pay. However, if your policy contains
				  an inflation protection feature where you choose to increase your benefits,
				  [Company Name] may increase your premium at that time for those additional
				  benefits.
(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;]
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the maximum type required to be
				  used for the other provisions of the outline of coverage, state whether or not
				  the company has a right to change the premium, and if a right exists, describe
				  clearly and concisely each circumstance under which the premium may
				  change.]
6. 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.]
7. 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 insurance producers] Neither [insert company name]
				  nor its [agents or insurance producers] 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.
8. 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.]
9. 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.]
(d) Eligibility for Payment of Benefits
[Activities of daily living and cognitive impairment shall be
				  used to measure an insured's need for long-term care and shall be defined and
				  described as part of the outline of coverage.]
[Any additional benefit triggers shall be explained in this
				  Section. If these triggers differ for different benefits, explanation of the
				  triggers shall 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.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Non-eligible facilities and providers;
(c) Non-eligible levels of care (e.g., unlicensed providers,
				  care or treatment provided by a family member, etc.);
(d) Exclusions and exceptions;
(e) Limitations.]
[This Section shall 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 paragraph
				  6 above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED
				  WITH YOUR LONG-TERM CARE NEEDS.
11. 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) Describe whether there will be any additional premium
				  charge imposed, and how that is to be calculated.]
12. 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.]
13. 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.]
14. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is used;
(b) Describe other important features.]
15. CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE
				  PROGRAM IF YOU HAVE GENERAL QUESTIONS REGARDING LONG-TERM CARE INSURANCE.
				  CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR
				  LONG-TERM CARE INSURANCE POLICY OR CERTIFICATE.