Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Appendix 031-425-F

Current through 2024-29, July 17, 2024
Contents and Format of Outline of
				  Coverage:
[on face page of outline]
IF YOU NEED ASSISTANCE, CONTACT :
Maine State Health Insurance
							 Assistance Program
MAINE BUREAU OF INSURANCE
CONSUMER HEALTH CARE DIVISION
34 STATE HOUSE STATION, AUGUSTA, ME
							 04333-0034
Tel. 207-624-8475 or
							 1-800-300-5000; Fax: 207-624-8599
INTERNET WEBSITE:
www.maine.gov/insurance
IF YOU HAVE GENERAL QUESTIONS REGARDING
							 LONG-TERM CARE INSURANCE. IN MAINE, CALL TOLL-FREE 1-877-ELDERS-1
							 (1-877-353-3771).
IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR
							 LONG-TERM CARE INSURANCE POLICY OR CERTIFICATE, CONTACT:
[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 cautionary 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
							 CONTINUED IN FORCE, DISCONTINUED OR CHANGED.
(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 noncancelable
							 shall contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE]
							 IS NONCANCELABLE. 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;]
(d) [State whether or not the company has a right to
							 change premium, and if such right exists, describe clearly and concisely each
							 circumstance under which premium may change.]
(e) The terms of the policy or certificate may change
							 from time to time, to conform to changes in the applicable laws or
							 rules.
4. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE
							 RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief description of the 30-day right
							 to return, or "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.]
5. 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 producers] Neither [insert company name] nor
							 its 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.
6. 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.]
7. BENEFITS PROVIDED BY THIS POLICY.
(a) [Covered services, related deductibles, 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 must be
							 defined and described as part of the outline of coverage.]
[Any additional benefit triggers must also be
							 explained. If these triggers differ for different benefits, an explanation of
							 the triggers 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.]
8. FEDERAL AND STATE INCOME TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] [RIDER] is intended to be
							 a federally tax-qualified long-term care insurance contract under Internal
							 Revenue Code § 7702 B(b), and also is intended to be a Maine tax-qualified
							 long-term care insurance contract pursuant to
							 36 M.R.S.A.
							 §5122(2)(L). The person
							 who pays premiums may be entitled to an income tax deduction. The insured
							 should seek the assistance of a personal tax advisor.
or
This [POLICY] [CERTIFICATE] is intended to be a
							 Maine state tax-qualified contract pursuant to
							 36 M.R.S.A.
							 §5122(2)(L). The person
							 who pays the premiums may be entitled to a Maine income-tax deduction. The
							 [policy][certificate][rider] is not intended to qualify for federal income tax
							 benefits. The insured should seek the assistance of a personal tax
							 advisor.
9. TAX ADVICE.
You should obtain advice from your personal tax
							 advisor.
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Non-eligible facilities and provider;
(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 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 Number 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
							 diseases and dementias. Specifically, describe each benefit screen or other
							 policy provision which preconditions 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.]