Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.31 - Long-Term Care › Rule 6.6.3114 - STANDARD FORMAT OUTLINE OF COVERAGE

Current through Register Vol. 13, July 5, 2024
(1) This
				rule implements, interprets and makes specific the provisions of
				33-22-1111,
				MCA, in prescribing a standard format and the content of an outline of
				coverage.
(2) The outline of
				coverage shall be a free-standing document, using no smaller than 10 point
				type.
(3) The outline of coverage
				shall contain no material of an advertising nature.
(4) Text which is capitalized or underscored
				in the standard format outline of coverage may be emphasized by other means
				which provide prominence equivalent to such capitalization or underscoring.
(5) Use of the text and sequence
				of text of the standard format outline of coverage is mandatory, unless
				otherwise specifically indicated.
(6) Format for outline of coverage:
[COMPANY NAME]
[ADDRESS-CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number of Group Master Policy and Certificate
				  Number]
[Except for policies or certificates which are guaranteed
				  issue, the following caution statement, or language substantially similar, must
				  appear as follows in the outline of coverage.] Caution: The issuance of this
				  long-term care insurance [policy][certificate] is based upon your responses to
				  the questions on your application. A copy of your [application][enrollment
				  form] [is enclosed][was retained by you when you applied]. If your answers are
				  incorrect or untrue, the company may have the right to deny benefits, or
				  rescind your policy or certificate. 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 or certificate contains governing contractual
				provisions. This means that the policy or certificate 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 7702B(b) of the
				  Internal Revenue Code of 1986, as amended.
OR
This [POLICY][CERTIFICATE] is not intended to be a federally
				  tax-qualified long-term care insurance contract under Section 7702B(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 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 [certificate] as long as you pay your premiums on time. [Company
				Name] cannot change any of the terms of your policy[certificate] 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 or 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 and cannot change the premium you currently
				pay. However, if your policy or certificate 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 or certificate.]
(b) [include a statement that the policy or
				certificate 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
				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 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.
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 or certificate 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/CERTIFICATE.
(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) [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, 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.]
10. LIMITATIONS AND EXCLUSIONS
[Describe:
(a)
				Preexisting conditions;
(b)
				Non-eligible facilities/provider;
(c) Non-eligible levels of care (e.g.,
				unlicensed providers, care or treatment provided by a family member,
				etc.)
(d)
				Exclusions/exceptions;
(e)
				Limitations.]
[This section should provide a brief specific description of
				  any policy provisions which limit, exclude, restrict, reduce, delay, or in any
				  other manner operate to qualify payment of the benefits described in (9)
				  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) And finally, describe whether there will
				be any additional premium charge imposed, and how that is to be calculated.]
12. ALZHEIMER'S
				DISEASE, IRREVERSIBLE DEMENTIA, AND OTHER ORGANIC BRAIN DISORDERS.
[State that the policy or certificate provides coverage for
				  insured clinically diagnosed as having Alzheimer's disease, irreversible
				  dementia, 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 or certificate;
(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 MONTANA STATE AUDITOR'S OFFICE, COMMISSIONER OF SECURITIES AND INSURANCE,
				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.