Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 8 - (90-102) Long-Term Care Insurance Regulation › Rule 19-3-8.17 - Standard Format Outline of Coverage

Current through June 25, 2024
This section of the Regulation implements, interprets and
				  makes specific, the provisions of Section 6E of this Regulation, in prescribing
				  a standard format and the content of an outline of coverage.
A. The outline of coverage shall be a
				free-standing document, using no smaller than ten-point type.
B. The outline of coverage shall contain no
				material of an advertising nature.
C. 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.
D. Use of the text
				and sequence of text of the standard format outline of coverage is mandatory,
				unless otherwise specifically indicated.
E. Format for outline of coverage:
(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, 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 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.)
4. 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 agents) Neither (inset company name)
				nor its agents 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.
5. 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.)
6. BENEFTIS PROVIDED BY THIS POLICY.
(a) (Covered services, related
				deductibles(s), waiting periods, elimination periods and benefit
				maximums.)
(b) (Institutional
				benefits, by skill level.)
(c)
				(Non-institutional benefits, by skill level.)
(Any benefit screens must be explained in this section. If
				  these screens differ for different benefits, explanation of the screen 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. If activities of daily
				  living (ADLs) are used to measure an insured's need for long-term care, then
				  these qualifying criteria or screens must be explained.)
7. 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 benefits described in (6)
				  above.)
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
				  YOUR LONG-TERM CARE NEEDS.
8. RELATIONSHIP OF COST OF CARE AND BENEFITS.
				Because the cost 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.)
9. TERMS UNDER WHICH THE POLICY (OR
				CERTIFICATE) MAY BE CONTINUED IN FORCE OR DISCONTINUED.
[
(a) Describe the
				policy renewability provisions:
(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 a right exists, describe clearly and
				concisely each circumstance under which premium may change.]
10. 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.)
11.
				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.]
12. ADDITIONAL FEATURES.
[
(a) Indicate if
				medical underwriting is used;
(b)
				Describe other important features.]