reglab/statecodes huggingface dataset:
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Section 031-420-9 - Payment of Claims

Current through 2024-29, July 17, 2024
Upon receipt of a notice of claim for benefits under a policy
				  or certificate of long-term care insurance delivered or issued for delivery in
				  this State, and after the insurer has sent the written statement required by
				   24-A M.R.S.A.
				  §5083(1) and received
				  the information identified in
				   24-A M.R.S.A.
				  §5083(2), a long-term
				  care insurer shall pay or deny the claim within 30 days, except as otherwise
				  permitted by this section. If the insurer is unable to decide the claim because
				  more information is needed, it may request necessary additional documentation,
				  consistent with Subsection A, with sufficient detail to permitthe insured to
				  understand and respond. The written request must be provided by the insurer
				  within 10 business days after receipt of the notice of claim. For purposes of
				  this section, "insured" includes the insured's authorized
				  representative.
A.
Documentation
The documentation an insurer may require of an insured
				  following the submission of a claim for benefits under a policy or certificate
				  of long-term care insurance is as follows:
1. A brief statement by or on behalf of the
				insured describing the basis of the claim for benefits;
2. A signed release permitting the insurer to
				obtain personal health information about the insured pursuant to the federal
Health Insurance Portability and Accountability Act of
				1996
;
3. A statement from
				the insured's physician, including the appropriate diagnosis and a treatment
				and care plan for the insured;
4. A
				statement from the long-term care provider rendering services to the insured,
				including an itemized bill for services, the provider's license number, and any
				daily nursing notes;
5. A copy of
				any power of attorney executed by the insured; and
6. Other information that the insurer
				determines is reasonably necessary to evaluate before making a determination on
				the claim and is not readily available from sources other than the
				insured.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Section 031-420-10 - Appealing a Claims Denial

Current through 2024-29, July 17, 2024
A.
Representation
. For purposes of this section and for section
				11, "insured" includes the insured's
				authorized representative.
B.
Notice
. An insurer shall provide clear written notice to the
				insured of any claims denial. The notice shall include:
1. The reason or reasons for the
				decision;
2. Reference to the
				specific contract provision on which the decision is based;
3. A description of any additional material
				or information necessary for the insured to perfect the claim and an
				explanation of why such material or information is necessary;
4. The insured's right to internal appeal in
				accordance with subsection C, including instructions and time limits for
				initiating the appeal, and the right to submit new or additional information
				relating to the claims denial with the appeal request;
5. The insured's right, after completion of
				the insurer's internal appeal process, to have the claims denial reviewed under
				the independent review process in accordance with Section
				11 if the claims denial is eligible
				for external review, and the right to file a complaint with the Superintendent
				after completion of at least one level of the insurer's internal review
				process.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Section 031-420-11 - External Review

Current through 2024-29, July 17, 2024
A.
Notice of
				External Review
. If the insurer's claims denial eligible for external
				review is upheld after completion of the insurer's internal appeal process
				outlined in section
				10, the insurer shall provide a
				written description of the insured's right to request an external review. The
				notice must include:
1. A description of the
				external review procedure and the requirements for making a request for
				external review;
2. A statement
				informing the insured how to request assistance from the insurer in filing a
				request for external review;
3. A
				statement informing the insured of the right to participate in the external
				review proceeding by teleconference or other reasonable means, to obtain and
				submit material in support of the claim, to ask questions of the insurer, and
				to have outside assistance; and
4.
				A statement informing the insured of the right to seek assistance or file a
				complaint with the Bureau and the toll-free number for the Bureau.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Section 031-420-12 - Transition

Current through 2024-29, July 17, 2024
A. Within four months after the effective
				date of the 2015 amendments to this Rule, every insurer shall file with the
				Superintendent any new forms or contract provisions, and all revisions to
				existing forms or contracts, which it will be using as a result of the
				amendments.
B. Every insurer
				required to file forms with the Superintendent and subject to this rule shall
				send all applicable forms and amended contract provisions to existing
				individual and group contract holders within 60 days after the first billing
				date after the form or contract provision has been approved by the
				Superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Section 031-420-13 - Effective date

Current through 2024-29, July 17, 2024
This rule is effective October 1, 2004. The 2008 amendments
				  are effective May 1, 2008. The 2015 amendments are effective March 30,
				  2015.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 420 - Nursing Home Care Insurance and Long-Term Care Insurance › Appendix 031-420-A

Current through 2024-29, July 17, 2024
Contingent Nonforfeiture
Cumulative Premium Increase over Initial
				  Premium
That qualifies for Contingent
				  Nonforfeiture
(Percentage increase is cumulative from date of original
				  issue. It does NOT represent a one-time increase.)
Issue Age
Percent Increase Over Initial Premium
29 and under
200%
30-34
190%
35-39
170%
40-44
150%
45-49
130%
50-54
110%
55-59
90%
60
70%
61
66%
62
62%
63
58%
64
54%
65
50%
66
48%
67
46%
68
44%
69
42%
70
40%
71
38%
72
36%
73
34%
74
32%
75
30%
76
28%
77
26%
78
24%
79
22%
80
20%
81
19%
82
18%
83
17%
84
16%
85
15%
86
14%
87
13%
88
12%
89
11%
90 and over
10%
* See Section
				  6(F)
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-1 - Purpose

Current through 2024-29, July 17, 2024
The purposes of this rule are to implement the Long-Term Care
				  Insurance law,
				  24-A M.R.S.A.
				  §§5071 -
				  5083, to
				  promote the public interest, to increase the availability of long-term care
				  insurance coverage, to protect applicants for long-term care insurance from
				  unfair or deceptive sales and enrollment practices, to facilitate public
				  understanding and comparison of long-term care coverages, and to encourage
				  flexibility and innovation in the development of long-term care
				  insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-2 - Authority

Current through 2024-29, July 17, 2024
The Superintendent of Insurance (the superintendent) adopts
				  this rule pursuant to the authority vested in him by
				  24
				  M.R.S.A. §§
										2316 and
				  2321
				  and by
				  24-A M.R.S.A.
				  §§212,
				  2412,
				  2413,
				  2414,
				  2736,
				  5071,
				  5072,
				  5073,
				  5074,
				  5075,
				  5077,
				  5078,
				  5080,
				  5083, and
				  5084.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-3 - Applicability and Scope

Current through 2024-29, July 17, 2024
Except as otherwise provided in
				  24-A M.R.S.A. §§
										5072(4)(A)-(C) and
				  5073,
				  this rule applies to: all individual and group long-term care insurance
				  policies; to long-term care insurance group certificates; and to individual and
				  group annuities and life insurance policies or riders that provide or
				  supplement coverage for long-term care insurance. The rule applies to any such
				  instrument delivered or issued for delivery in this state on and after the
				  effective date of this rule and to any product advertised, marketed or offered
				  in this state as long-term care insurance. The entities subject to this rule
				  are: insurers; fraternal benefit societies; non-profit health care, hospital
				  and medical service corporations; health maintenance organizations; prepaid
				  health plan organizations; and other similar entities as defined in
				  24-A M.R.S.A.
				  §5072(4). The rule does
				  not apply to certificates delivered under policies issued in other states to
				  employer groups described in
				  24-A M.R.S.A.
				  §2804, and to labor union groups
				  described in
				   24-A M.R.S.A.
				  §2805.
(Drafting Note:
This
				  rule does not apply to contracts issued or issued for delivery in other states
				  even if the insured becomes a resident of this state.)
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-4 - Rule Definitions

Current through 2024-29, July 17, 2024
As used in this rule, unless the context otherwise indicates,
				  the following terms have the following meanings:
A. "Adverse benefit trigger determination"
				means a claims denial determining that the insured has not satisfied a required
				clinical standard for benefit eligibility, as described more fully in Sections
				27 and
				28, including, when applicable under
				the contract, the existence or degree of cognitive impairment, chronic illness,
				or inability to perform one or more specified activities of daily
				living.
B. "Authorized
				representative" means:
(1) A person to whom
				an insured has given express written consent to represent the insured in a
				standard appeal or an external review;
(2) A person authorized by law to provide
				consent to request an internal appeal or an external review for an insured;
				or
(3) A family member of an
				insured or an insured's treating health care professional when the insured is
				unable to provide consent to request an internal appeal or an external review.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-6 - Meaning of "Guaranteed Renewable" and "Noncancelable"; Allowed Limitations and Exclusions

Current through 2024-29, July 17, 2024
A.
Renewability
. The terms "guaranteed renewable" or "noncancelable"
				shall be used in any long-term care insurance policy along with a disclosure,
				as required by Section
				8, defining or explaining the terms.
(1) No policy shall contain any renewal
				provision other than "guaranteed renewable" or "noncancelable."
(2) The term "guaranteed renewable" may be
				used only if the insured has the right to continue the insurance in force by
				the timely payment of premiums and if the insurer (a) has no unilateral
				contractual right to change any policy provision while the insurance is in
				force or (b) has no right to decline renewal, except on prior approval from the
				superintendent to a rate change on a class basis that applies statewide. The
				definition of "class" may not be based on health status or claims
				experience.
(3) The term
				"noncancelable" may be used only if the insured has the right to continue the
				policy in force by the timely payment of premiums and the insurer has no
				unilateral right to change any policy provision or the premium rate.
(4) The term "level premium" may be used only
				when the insurer does not have the right to change the premium.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-7 - Preventing Unintentional Lapse of Coverage

Current through 2024-29, July 17, 2024
As protection against unintentional lapse, each insurer
				  offering long-term care insurance shall comply with the following
				  requirements:
A.
Notice Before
				Lapse or Termination Date
(1) No
				individual policy or certificate shall be issued until the insurer has received
				from the applicant either a written designation of at least one person, in
				addition to the applicant, who is to receive notice of lapse or termination of
				the policy or certificate for nonpayment of premium, or a written waiver dated
				and signed by the applicant electing not to designate additional persons to
				receive notice. The applicant has the right to designate at least one person
				who is to receive the notice of termination, in addition to the insured.
				Designation shall not constitute acceptance of any liability on the third party
				for services provided to the insured. The form used for the written designation
				must provide space clearly designated for listing at least one person. The
				designation shall include each person's
full name
and
home address
. In the case of an applicant who elects not to
				designate an additional person, the waiver shall state: "Protection against
				unintended lapse. I understand that I have the right to designate at least one
				person other than myself to receive notice of lapse or termination of this
				long-term care insurance policy for nonpayment of premium. I understand that
				notice will not be given until 30 days after a premium is due and unpaid. I
				elect NOT to designate a person to receive this notice." The insurer shall
				notify the insured of the right to change this written designation, no less
				often than once every two years.
(2) When the policyholder or
				certificateholder pays the premium for a policy or certificate through a
				payroll or pension deduction plan, the requirements of Paragraph (1) need not
				be met until 60 days after the policyholder or certificateholder is no longer
				on such a payment plan. The application or enrollment form for such policies or
				certificates shall clearly indicate the payment plan selected by the
				applicant.
(3) Lapse or termination
				for nonpayment of premium. No individual policy or certificate shall lapse or
				be terminated for nonpayment of premium unless the insurer, at least 30 days
				before the effective date of the lapse or termination, has given notice to the
				insured and to those persons designated pursuant to Section 7(A)(1), at the
				address or addresses provided by the insured for purposes of receiving notice
				of lapse or termination. Notice shall be given by first class United States
				mail, postage prepaid. Notice may not be given until 30 days after a premium is
				due and unpaid. Notice shall be deemed to have been given as of five days after
				the date of mailing.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-8 - Policy Disclosures

Current through 2024-29, July 17, 2024
A.
Renewability
. All long-term care insurance policies shall contain
				a renewability provision. The provision shall be appropriately captioned, shall
				appear on the first page of the policy, and shall clearly state that the
				coverage is guaranteed renewable or noncancelable. This subsection shall not
				apply to policies that do not contain a renewability provision and under which
				the right to nonrenew is reserved solely to the policyholder.
B.
Riders and Endorsements
.
				Except for riders or endorsements that effectuate a request made in writing by
				the insured under an individual policy after date of issue or at reinstatement
				or renewal that reduce or eliminate the policy, all riders or endorsements
				added to an individual long-term care insurance policy after the date of issue
				or at reinstatement or renewal that 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 that increases benefits or
				coverage with a concomitant increase in premium during the policy term must be
				agreed to in a writing signed by the insured, except if the increased benefits
				or coverage are required by law. Where a separate additional premium is charged
				for benefits provided in connection with riders or endorsements, the premium
				charge shall be set forth in the policy, rider or endorsement.
C.
Payment of Benefits
. A policy
				that provides for the payment of benefits based on standards described as
				"usual and customary," "reasonable and customary," or words of similar import,
				shall comply with the following requirements:
(1) It must include a definition of these
				terms and an explanation of the terms in its accompanying outline of
				coverage.
(2) It must clearly
				disclose that the insured or enrollee may be subject to balance billing as a
				result of claims adjustment
(3) It
				must provide a toll-free number that an insured or enrollee may call prior to
				receiving services to determine the maximum allowable charge permitted by the
				carrier for a specified service.
(4) The carrier must provide to the
				superintendent on request complete information on the methodology and specific
				data used by the carrier or any 3rd party on behalf of the carrier in adjusting
				any claim submitted by or on behalf of the insured or enrollee. In considering
				the reasonableness of the methodology for calculating maximum allowable
				charges, the superintendent shall consider whether the methodology takes into
				account relevant data specific to this State if there is sufficient data to
				constitute a representative sample of charge data for the same or comparable
				service.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-9 - Disclosing Rating Practices to Applicants

Current through 2024-29, July 17, 2024
A.
				This section shall apply as follows:
(1)
				Except as provided in Section 9(A)(2), this section applies to any long-term
				care policy or certificate delivered or issued for delivery in this state on or
				after October 1, 2004.
(2) For
				certificates issued under a group long-term care policy issued to an employee
				group as defined in
				 24-A M.R.S.A.
				§2804, a labor union groups as defined
				in
				24-A M.R.S.A.
				§2805, or a trustee groups as defined in
				24-A M.R.S.A.
				§2806, which policy is in force on or
				after the effective date of this rule, the provisions of this section shall
				apply on or after the first policy anniversary following April 1,
				2005.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-11 - Prohibition Against Post-Claims Underwriting

Current through 2024-29, July 17, 2024
A.
				All applications for long-term care insurance policies or certificates, except
				those that are guaranteed issue, shall contain clear and unambiguous questions
				designed to ascertain the health condition of the applicant.
B.
(1) If
				an application for long-term care insurance contains a question that asks
				whether the applicant has had medication prescribed by a physician, it must
				also ask the applicant to list the medication that has been
				prescribed.
(2) If the medications
				listed in the application were known by the insurer, or should have been known
				at the time of application, to be directly related to a medical condition for
				which coverage would otherwise be denied, then the policy or certificate shall
				not be rescinded for that condition.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-12 - Minimum Home Care and Community Care Benefits

Current through 2024-29, July 17, 2024
A.
				A long-term care insurance policy or certificate, if it provides benefits for
				home health care or community care services, shall not limit or exclude
				benefits in any of the following ways:
(1) By
				requiring that the insured or claimant would need care in a skilled nursing
				facility if home health care services were not provided;
(2) By requiring that the insured or claimant
				first or simultaneously receive nursing or therapeutic services, or both, in a
				home, community or institutional setting before home care services are
				covered;
(3) By limiting eligible
				services to services provided by registered nurses or licensed practical
				nurses;
(4) By requiring that a
				nurse or therapist provide services covered by the policy that can be provided
				by a home health aide, or other licensed or certified home care worker acting
				within the scope of his or her licensure or certification;
(5) By excluding coverage for personal care
				services provided by a home health aide;
(6) By requiring that the provision of home
				health care services be at a level of certification or licensure greater than
				that required by the eligible service;
(7) By requiring that the insured or claimant
				have an acute condition before home health care services are covered;
(8) By limiting benefits to services provided
				by Medicare-certified agencies or providers; or
(9) By excluding coverage for adult day care
				services.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-13 - Required Offer of Inflation Benefit

Current through 2024-29, July 17, 2024
A. No insurer may
				offer a long-term care insurance policy unless the insurer also offers to the
				policyholder, in addition to any other inflation protection, the option to
				purchase a policy that provides for benefit levels to increase with benefit
				maximums or reasonable durations which are meaningful to account for reasonably
				anticipated increases in the costs of long-term care services covered by the
				policy. Insurers must offer to each policyholder, at the time of purchase, the
				option to purchase a policy with an inflation protection feature no less
				favorable than one of the following:
(1)
				Increases benefit levels annually in a manner so that the increases are
				compounded annually at a rate not less than five percent;
(2) Guarantees the insured individual the
				right to periodically increase benefit levels without providing evidence of
				insurability or health status so long as the option for the previous period has
				not been declined. The amount of the additional benefit shall be no less than
				the difference between the existing policy benefit and that benefit compounded
				annually at a rate of at least five percent for the period beginning with the
				purchase of the existing benefit and extending until the year in which the
				offer is made; or
(3) Covers a
				specified percentage of actual or reasonable charges and does not include a
				maximum specified indemnity amount or limit.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-14 - Replacing Existing Insurance: Cautionary Notice to Applicant

Current through 2024-29, July 17, 2024
A. Application forms shall include the
				following questions designed to elicit whether, as of the date of the
				application, the applicant has another long-term care insurance policy or
				certificate in force or whether a long-term care policy or certificate is
				intended to replace any other accident and sickness or long-term care policy or
				certificate presently in force. A supplementary application or other form to be
				signed by the applicant and the producer, except where the coverage is sold
				without a producer, containing the questions may be used. With regard to a
				group replacement policy issued to an employee group as defined in
				 24-A M.R.S.A.
				§2804, a labor union group as defined in
				24-A M.R.S.A.
				§2805, or a trustee group as defined in
				24-A M.R.S.A.
				§2806, questions may be modified only to
				the extent necessary to elicit information about health or long-term care
				insurance policies other than the group policy being replaced, provided that
				certificate holders have been notified of the replacement.
(1) Do you have another long-term care
				insurance policy or certificate in force (including health care service
				contract or health maintenance organization contract)?
(2) Did you have another long-term care
				insurance policy or certificate in force during the last twelve (12) months?
(a) If so, with which company?
(b) If that policy lapsed, when did it
				lapse?
(3) Are you
				covered by Medicaid?
(4) Do you
				intend to replace any of your medical or health insurance coverage with this
				policy [certificate]?
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-15 - Prohibition Against New Preexisting Condition Exclusions and Probationary Periods in Replacement Plans

Current through 2024-29, July 17, 2024
If a long-term care insurance 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
				  in the new long-term care policy for similar benefits to the extent that
				  similar exclusions have been satisfied under the original
				  policy.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-16 - Annual Reports to Superintendent: Lapsed and Replaced Policies

Current through 2024-29, July 17, 2024
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, on a form prescribed by the superintendent, the
				number of lapsed policies as of the end of the preceding calendar
				year.
C. Every insurer shall report
				annually by June 30, on a form prescribed by the superintendent, for qualified
				long-term care insurance contracts, the number of claims denied for each class
				of business, expressed as a percentage of claims denied, and:
(1) the number of denied claims appealed to a
				first level review;
(2) the number
				of first level appeals overturned and the number upheld;
(3) the number of denied claims appealed to a
				second level review; and
(4) the
				number of second level reviews overturned and the number upheld.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-17 - Licensing of Producers

Current through 2024-29, July 17, 2024
A producer is not authorized to sell, solicit the
				  application for, or negotiate with respect to long-term care insurance, except
				  as authorized by the producer licensing requirements of
				  24-A M.R.S.A.
				  §§1401
et
				  seq.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-18 - Discretionary Powers of Superintendent

Current through 2024-29, July 17, 2024
Upon written request and after an administrative hearing,
				  the superintendent may issue an order to modify or suspend a specific provision
				  or provisions of this rule with respect to a specific long-term care insurance
				  policy or certificate upon a written finding that:
A. The modification or suspension would be in
				the best interest of the insureds;
B. The purposes to be achieved could not be
				effectively or efficiently achieved without the modification or suspension; and
				C.
(1) The modification or suspension is
				necessary to the development of an innovative and reasonable approach for
				insuring long-term care; or
(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 modification or suspension is reasonably related to the special needs
				or nature of such a community; or
(3) The modification or suspension is
				necessary to permit long-term care insurance to be sold as part of, or in
				conjunction with, another insurance product.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-19 - Reserve Standards

Current through 2024-29, July 17, 2024
A. Except as
				provided in subsection B, an insurer that provides long-term care benefits
				shall determine reserves in accordance with applicable law referring to minimum
				health insurance reserves, or with the NAIC version which requires reserves
				using a table established for reserve purposes by a qualified actuary and
				acceptable to the superintendent.
B. If an insurer provides long-term care
				benefits through the acceleration of benefits under group or individual life
				policies or riders to such policies, policy reserves for the benefits shall be
				determined in accordance with
				24-A M.R.S.A.
				§§951 -
				962. Claim
				reserves also shall be established when the policy or rider is in claim status.
Reserves for policies and riders subject to this subsection
				  should be based on the multiple decrement model utilizing 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.
In the development and calculation of reserves for policies
				  and riders subject to this subsection, due regard shall be given to the
				  applicable policy provisions, marketing methods, administrative procedures and
				  all other considerations which have an impact on projected claim costs,
				  including, but not limited to, the following:
(1) Definition of insured events;
(2) Covered long-term care
				facilities;
(3) Existence of home
				convalescent care coverage;
(4)
				Definition of facilities;
(5)
				Existence or absence of barriers to eligibility;
(6) Premium waiver provision;
(7) Renewability;
(8) Ability to raise premiums;
(9) Marketing method;
(10) Underwriting procedures;
(11) Claims adjustment procedures;
(12) Waiting period;
(13) Maximum benefit;
(14) Availability of eligible
				facilities;
(15) Margins in claim
				costs;
(16) Optional nature of
				benefit;
(17) Delay in eligibility
				for benefit;
(18) Inflation
				protection provisions; and
(19)
				Guaranteed insurability option.
Any applicable valuation morbidity table shall be certified
				  as appropriate as a statutory valuation table by a member of the American
				  Academy of Actuaries.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-20 - Premium Rate Increase Procedures

Current through 2024-29, July 17, 2024
A. This section
				shall apply as follows:
(1) Except as provided
				in Section 20(A)(2), this section applies to any long-term care policy or
				certificate delivered or issued for delivery in this state on or after October
				1, 2004.
(2) For certificates
				issued under a group long-term care policy issued to an employee group as
				defined in
				24-A M.R.S.A.
				§2804, a labor union group as defined in
				24-A M.R.S.A.
				§2805, or a trustee group as defined in
				24-A M.R.S.A.
				§2806, which policy is in force on or
				after the effective date of this rule, the provisions of this section shall
				apply on or after the first policy anniversary following April 1,
				2005.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-21 - Filing of Advertising with Superintendent

Current through 2024-29, July 17, 2024
A.
				Every insurer, health care service plan or other entity providing long-term
				care insurance in this state shall file with the superintendent for prior
				approval a copy of any long-term care insurance advertisement intended for use
				in this state, whether through written, radio, television, internet or other
				medium. If the advertisement has not been affirmatively approved or disapproved
				within 30 days after filing, it will be deemed approved.
B. The superintendent may exempt from the
				requirement of prior approval any advertising form or material when, in the
				superintendent's opinion, this requirement may not be reasonably
				applied.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-22 - Standards for Marketing

Current through 2024-29, July 17, 2024
A. Every insurer,
				health care service plan or other entity marketing long-term care insurance
				coverage in this state, directly or through its producers, shall:
(1) Establish marketing procedures and
				producer training requirements to assure that:
(a) Any marketing activity, including
				comparison of policies by its producers, will be fair and accurate;
				and
(b) Excessive insurance is not
				sold or issued.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-23 - Applicant's Suitability for Long-term Care Insurance

Current through 2024-29, July 17, 2024
A. This section shall not apply to life
				insurance policies that accelerate benefits for long-term care.
B. Every insurer, health care service plan or
				other entity marketing long-term care insurance shall:
(1) Develop and use suitability standards to
				determine whether the purchase or replacement of long-term care insurance is
				appropriate for the needs of the applicant;
(2) Train its producers in the use of its
				suitability standards; and
(3)
				Maintain a copy of its suitability standards and make them available for
				inspection upon request by the superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-24 - Availability of New Services or Providers

Current through 2024-29, July 17, 2024
A. An
				insurer shall notify policyholders of the availability of a new long-term care
				policy series that provides coverage for new long-term care services or
				providers material in nature and not previously available through the insurer
				to the general public. The notice shall be provided within twelve (12) months
				of the date the new policy series is made available for sale in this
				state.
B. Notwithstanding
				Subsection A above, notification is not required for any policy issued prior to
				the effective date of this rule or to any policyholder or certificateholder who
				is currently eligible for benefits, within an elimination period or on claim,
				or who previously has been in claim status, or who would not be eligible to
				apply for coverage due to issue age limitations under the new policy. The
				insurer may require that policyholders meet all eligibility requirements,
				including underwriting and payment of the required premium to add such new
				services or providers.
C. The
				insurer shall make the new coverage available in one of the following ways:
(1) By adding a rider to the existing policy
				and charging a separate premium for the new rider based on the insured's
				attained age;
(2) By exchanging the
				existing policy or certificate for one with an issue age based on the present
				age of the insured and recognizing past insured status by granting premium
				credits toward the premiums for the new policy or certificate. The premium
				credits shall be based on premiums paid or reserves held for the prior policy
				or certificate;
(3) By exchanging
				the existing policy or certificate for a new policy or certificate in which
				consideration for past insured status shall be recognized by setting the
				premium for the new policy or certificate at the issue age of the policy or
				certificate being exchanged. The cost for the new policy or certificate may
				recognize the difference in reserves between the new policy or certificate and
				the original policy or certificate; or
(4) By an alternative program developed by
				the insurer that meets the intent of this section if the program is filed with
				and approved by the superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-25 - Right to Reduce Coverage and Lower Premiums

Current through 2024-29, July 17, 2024
A.
(1) Every long-term care insurance policy and
				certificate shall include a provision that allows the policyholder or
				certificateholder to reduce coverage and lower the policy or certificate
				premium in at least one of the following ways:
(a) Reducing the maximum benefit;
				or
(b) Reducing the daily, weekly
				or monthly benefit amount.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-26 - Required Offer of Nonforfeiture Benefit; Contingent Nonforfeiture Benefit Upon Lapse

Current through 2024-29, July 17, 2024
A. This section
				does not apply to life insurance policies or riders containing accelerated
				long-term care benefits.
B. To
				comply with the requirement to offer a nonforfeiture benefit to policyholders
				and certificateholders pursuant to
				24-A M.R.S.A.
				§§5077(1) and
				5077(2):
(1) A policy or certificate offered with
				nonforfeiture benefits shall have coverage elements, eligibility, benefit
				triggers and benefit length that are the same as coverage to be issued without
				nonforfeiture benefits. The nonforfeiture benefit included in the offer shall
				be the benefit described in Section 26(D); and
(2) The offer shall be in writing if the
				nonforfeiture benefit is not otherwise described in the Outline of Coverage or
				other materials given to the prospective policyholder.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-27 - Standards for Benefit Triggers

Current through 2024-29, July 17, 2024
A. A long-term care
				insurance policy shall condition the payment of benefits on a determination of
				the insured's ability to perform activities of daily living and on cognitive
				impairment. Eligibility for the payment of benefits shall not be more
				restrictive than requiring either a deficiency in the ability to perform not
				more than three of at least five of the activities of daily living or the
				presence of cognitive impairment.
B. Insurers may use activities of daily
				living, other than those listed in Section
				5, to trigger covered benefits as long
				as they are defined in the policy.
C. An insurer may use additional provisions
				for the determination of when benefits are payable under a policy or
				certificate; however the provisions shall not restrict, and are not in lieu of,
				the requirements contained in Sections 27(A) and (B).
D. For purposes of this section the
				determination of a deficiency shall not be more restrictive than:
(1) Requiring the hands-on assistance of
				another person to perform the prescribed activities of daily living;
				or
(2) If the deficiency is due to
				the presence of a cognitive impairment, supervision or verbal cueing by another
				person is needed in order to protect the insured or others.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-28 - Additional Standards for Benefit Triggers for Federally Qualified Long-term Care Insurance Contracts

Current through 2024-29, July 17, 2024
A. For purposes of
				this section the following definitions apply:
(1) "Federally qualified long-term care
				services" means services that meet the requirements of Section 7702 B(c)(1) of
				the Internal Revenue Code of 1986, as amended, as follows: necessary
				diagnostic, preventive, therapeutic, curative, treatment, mitigation and
				rehabilitative services, and maintenance or personal care services which are
				required by a chronically ill individual, and are provided pursuant to a plan
				of care prescribed by a licensed health care practitioner.
(2)
(a)
				"Chronically ill individual" has the meaning prescribed for this term by
				section 7702 B(c)(2) of the Internal Revenue Code of 1986, as amended. Under
				this provision, a chronically ill individual means any individual who has been
				certified by a licensed health care practitioner as:
(i) Being unable to perform (without
				substantial assistance from another individual) at least two (2) activities of
				daily living for a period of at least ninety (90) days due to a loss of
				functional capacity; or
(ii)
				Requiring substantial supervision to protect the individual from threats to
				health and safety due to severe cognitive impairment.
(b) The term "chronically ill individual"
				shall not include an individual otherwise meeting these requirements unless
				within the preceding twelve-month period a licensed health care practitioner
				has certified that the individual meets these requirements.
(3) "Licensed health care
				practitioner" means a physician, as defined in Section 1861(r)(1) of the Social
				Security Act, a registered professional nurse, licensed social worker or other
				individual who meets requirements prescribed by the Secretary of the
				Treasury.
(4) "Maintenance or
				personal care services" means any care the primary purpose of which is the
				provision of needed assistance with any of the disabilities as a result of
				which the individual is a chronically ill individual (including the protection
				from threats to health and safety due to severe cognitive
				impairment).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-29 - Delivery of Outline of Coverage; Standard Format for Outline

Current through 2024-29, July 17, 2024
A. Every solicitation or marketing of a
				long-term care insurance policy, rider or certificate must include delivery of
				an outline of each long-term care product the producer or insurer is soliciting
				or marketing to the individual. The outline(s) shall be delivered to the
				prospective applicant or enrollee no later than the time of "first
				solicitation," through means that prominently direct the attention of the
				recipient to the document.
B.
				"First solicitation" means, in the case of producer solicitations, the time
				when the producer initially sends or presents to the individual any document
				materially relating to the long-term care insurance coverage the producer is
				soliciting. Procedural communications, such as setting up an appointment or
				direct mail asking the consumer to return a post card if he wishes further
				information, are not material, and therefore not first solicitations. For
				direct response solicitations, the "first solicitation" is the time the insurer
				initially sends or presents to the individual any document the prospective
				applicant requested in the response. The producer in any event shall deliver
				the outline(s) at the earliest possible time before sending or presenting an
				application or enrollment form, and the insurer shall deliver the outline(s) no
				later than the time it submits the application or enrollment form for
				signature.
C. Every application,
				enrollment or similar form shall contain an acknowledgement of receipt of the
				outline of coverage. The acknowledgement shall provide for the applicant's
				signature, the date the applicant receives the outline, and a statement that
				the outline was received on the first solicitation by the producer or
				insurer.
D. For every
				producer-solicited application there shall be a producer's statement in the
				application, enrollment or similar form. The producer's statement shall include
				the producer's signature, the date the producer delivers the outline, and a
				statement that the delivery was made at the time of the first
				solicitation.
E. For group
				insurance, the insurer may request the superintendent to allow use of a
				substitute form in place of the outline of coverage.
F. The mandatory contents for the outline of
				coverage appear in
Appendix F.
The outline of coverage shall be a
				free-standing document, using no smaller than 12 point type, and shall contain
				no material of an advertising nature. Text that is capitalized or underscored
				in the standard format outline of coverage may be emphasized by other means
				that provide prominence equivalent to the capitalization or
				underscoring.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-30 - Delivery of Shopper's Guide

Current through 2024-29, July 17, 2024
A. A long-term care
				insurance shopper's guide in the format developed by the National Association
				of Insurance Commissioners shall be provided to all prospective applicants of a
				long-term care insurance policy or certificate.
B. In the case of producer solicitations, a
				producer shall deliver the shopper's guide at the producer's "first
				solicitation," as defined in Section
				29(B).
C. In the case of direct response
				solicitations, the insurer shall deliver the shopper's guide no later than the
				time of its "first solicitation," as defined in Section
				29(B).
D. For life insurance policies or riders
				containing accelerated long-term care benefits, insurers and producers are not
				required to furnish the shopper's guide; however, they shall furnish a life
				insurance policy summary as required by
				24-A M.R.S.A.
				§5074(4).