Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 19 - Regulation 46-Long-Term Care Insurance › Section XIII-1969 - Appendices (Formerly 1961)

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				Appendix A
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
				  FOR THE STATE OF LOUISIANA FOR THE REPORTING YEAR 20[ ]
Company Name: _______________________________
Address: ______________________
				  ______________________________
				  ____________________________________________________________
Phone Number: _______________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of
				  long-term care insurance policies or certificates. Those rescissions
				  voluntarily effectuated by an insured are not required to be included in this
				  report. Please furnish one form per rescission.
Policy Form Number
Policy and Certificate Number
Name
of Insured
Date of Policy Issuance
Date/s Claim/s Submitted
Date of Rescission
Detailed reason for rescission:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
______________________
Signature
______________________________________
Name and Title (please type)
______________________________________
Date
B.
				Appendix B
LONG-TERM CARE INSURANCE
PERSONAL WORKSHEET
People buy long-term care insurance for many reasons. Some
				  don't want to use their own assets to pay for long-term care. Some buy
				  insurance to make sure they can choose the type of care they get. Others don't
				  want their family to have to pay for care or don't want to go on Medicaid. But
				  long-term care insurance may be expensive, and may not be right for
				  everyone.
By state law the insurance company must fill out part of the
				  information on this worksheet and
ask
you to fill out the rest to
				  help you and the company decide if you should buy this policy.
PREMIUM INFORMATION
Policy Form Numbers
_________________________________________
The premium for the coverage you are considering will be [$
				  _________per month, or $________ per year.] [a one-time single premium of
				  $_________.]
Type of Policy (noncancellable/guaranteed
				  renewable):
______________
The Company's Right to Increase Premiums:
______________________
[The company cannot raise your rates on this policy.] [The
				  company has a right to increase premiums on this policy form in the future,
				  provided it raises rates for all policies in the same class in this state.]
				  [Insurers shall use appropriate bracketed statement. Rate guarantees shall not
				  be shown on this form.]
Rate Increase History
The company has sold long-term care insurance since [year]
				  and has sold this policy since [year]. [The company has never raised its rates
				  for any long-term care policy it has sold in this state or any other state.]
				  [The company has not raised its rates for this policy form or similar policy
				  forms in this state or any other state in the last 10 years.] [The company has
				  raised its premium rates on this policy form or similar policy forms in the
				  last 10 years. Following is a summary of the rate increases.]
Questions Related to Your Income
How will you pay each year's premiums?
[] From my Income [] From my Savings/Investments [] My Family
				  will Pay
What is your annual income? (check one)
[] Under $10,000 [] $[10-20,000] [] $[20-30,000]
[] $[30-50,000] [] Over $50,000
How do you expect your income to change over the next 10
				  years? (check one)
[] No change [] Increase [] Decrease
If you will be paying premiums with money received
				  only from your own income, a rule of thumb is that you may not be able to
				  afford this policy if the premiums will be more than 7 percent of your income.
Will you buy inflation protection? (check one)
[] Yes
[] No
If not, have you considered how you will pay for the
				  difference between future costs and your daily benefit amount?
[] From my Income [] From my Savings/Investments [] My Family
				  will Pay
The national average annual cost of care in [insert
				  year] was [insert $ amount], but this figure varies across the country. In ten
				  years the national average annual cost would be about [insert $ amount] if
				  costs increase 5% annually.
What elimination period are you considering?
Number of days ______ Approximate cost $_______ for that
				  period of care.
How are you planning to pay for your care during the
				  elimination period? (check one)
[] From my Income [] From my Savings/Investments [] My Family
				  will Pay
[[] Have you considered whether you could afford to keep this
				  policy if the premiums went up, for example, by 20%?]
Questions Related to Your Savings and
				  Investments
Not counting your home, about how much are all of your assets
				  (your savings and investments) worth? (check one)
[]Under $20,000 [] $20,000-$30,000 [] $30,000-$50,000 []Over
				  $50,000
How do you expect your assets to change over the next ten
				  years? (check one)
[] Stay about the same [] Increase [] Decrease
If you are buying this policy to protect your assets
				  and your assets are less than $30,000, you may wish to consider other options
				  for financing your long-term care.
Disclosure Statement
[] The answers to the questions above describe my
							 financial situation.
or
[] I choose not to complete this information.
(Check one.)
[] I acknowledge that the carrier and/or its producer
							 (below) has reviewed this form with me including the premium, premium rate
							 increase history and potential for premium increases in the future. [For direct
							 mail situations, use the following: I acknowledge that I have reviewed this
							 form including the premium, premium rate increase history and potential for
							 premium increases in the future.] I understand the above disclosures.
I
							 understand that the rates for this policy may increase in the future
.
							 (This box must be checked).
Signed:_____________________
				  ___________________________
(Applicant) (Date)
[ [] I explained to the applicant the importance of
				  completing this information.
Signed:_____________________
				  ____________________________
(Producer) (Date)
Producer's Printed
				  Name:________________________________________]
[In order for us to process your application, please return
				  this signed statement to [name of company], along with your
				  application.]
[My producer has advised me that this policy does not seem to
				  be suitable for me. However, I still want the company to consider my
				  application.
Signed:______________________
				  ___________________________]
(Applicant) (Date)
The company may contact you to verify your answers.
C. Appendix
				C
THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE
				  INSURANCE
Long-Term Care Insurance
* A long-term care insurance policy may pay most of
							 the costs for your care in a nursing home. Many policies also pay for care at
							 home or other community settings. Since policies can vary in coverage, you
							 should read this policy and make sure you understand what it covers before you
							 buy it.
* [You should
not
buy this insurance
							 policy unless you can afford to pay the premiums every year.] [Remember that
							 the company can increase premiums in the future.]
* The personal worksheet includes questions designed
							 to help you and the company determine whether this policy is suitable for your
							 needs.
Medicare
* Medicare does
not
pay for most
							 long-term care.
Medicaid
* Medicaid will generally pay for long-term care if
							 you have very little income and few assets. You probably should
not
buy this policy if you are now eligible for Medicaid.
* Many people become eligible for Medicaid after they
							 have used up their own financial resources by paying for long-term care
							 services.
* When Medicaid pays your spouse's nursing home
							 bills, you are allowed to keep your house and furniture, a living allowance,
							 and some of your joint assets.
* Your choice of long-term care services may be
							 limited if you are receiving Medicaid. To learn more about Medicaid, contact
							 your local or state Medicaid agency.
Shopper's Guide
* Make sure the insurance company or producer gives
							 you a copy of a book called the National Association of Insurance
							 Commissioners' "Shopper's Guide to Long-Term Care Insurance." Read it
							 carefully. If you have decided to apply for long-term care insurance, you have
							 the right to return the policy within 30 days and get back any premium you have
							 paid if you are dissatisfied for any reason or choose not to purchase the
							 policy.
Counseling
* Free counseling and additional information about
							 long-term care insurance are available through your state's insurance
							 counseling program. Contact your state insurance department or department on
							 aging for more information about the senior health insurance counseling program
							 in your state.
Facilities
* Some long-term care insurance contracts provide
							 for benefit payments in certain facilities only if they are licensed or
							 certified, such as in assisted living centers. However, not all states regulate
							 these facilities in the same way. Also, many people move into a different state
							 from where they purchased their long-term care insurance policy. Read the
							 policy carefully to determine what types of facilities qualify for benefit
							 payments, and to determine that payment for a covered service will be made if
							 you move to a state that has a different licensing scheme for facilities than
							 the one in which you purchased the policy.
D. Appendix
				D
LONG-TERM CARE INSURANCE SUITABILITY
				  LETTER
Dear [Applicant]:
Your recent application for long-term care insurance included
				  a "personal worksheet," which asked questions about your finances and your
				  reasons for buying long-term care insurance. For your protection, state law
				  requires us to consider this information when we review your application, to
				  avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not
				  meet your financial needs. We suggest that you review the information provided
				  along with your application, including the booklet "Shopper's Guide to
				  Long-Term Care Insurance" and the page titled "Things You Should Know Before
				  Buying Long-Term Care Insurance." Your state insurance department also has
				  information about long-term care insurance and may be able to refer you to a
				  counselor free of charge who can help you decide whether to buy this
				  policy.]
[You chose not to provide any financial information for us to
				  review.]
We have suspended our final review of your application. If,
				  after careful consideration, you still believe this policy is what you want,
				  check the appropriate box below and return this letter to us within the next 60
				  days. We will then continue reviewing your application and issue a policy if
				  you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				  close your file and not issue you a policy. You should understand that you will
				  not have any coverage until we hear back from you, approve your application and
				  issue you a policy.
Please check one box and return in the enclosed
				  envelope.
[] Yes, [although my worksheet indicates that long-term care
				  insurance may not be a suitable purchase,] I wish to purchase this coverage.
				  Please resume review of my application.
[] No. I have decided not to buy a policy at this
				  time.
____________________________ _________________________
Applicant Signature Date
Please return to [issuer] at [address] by [date].
E. Appendix E
CLAIMS DENIAL REPORTING FORM LONG-TERM CARE
				  INSURANCE
For the State
				  of__________________________
For the Reporting Year of
_________________
Company Name:_________________Due: June 30 annually
Company Address:_________________________________
________________________________________
________________________________________
Company NAIC Number:_____________________________
Contact Person:
__________
Phone
				  Number:______________
Line of Business:
_______
Individual
_______
Group______
Instructions
The purpose of this form is to report all long-term care
				  claim denials under in force long-term care insurance policies. Indicate the
				  manner of reporting by checking one of the boxes below:
[] Per claimant - counts each individual who makes one or a
				  series of claim requests.
[] Per transaction - counts each claim payment request.
				  "Denied" means a claim that is not paid for any reason other than for claims
				  not paid for failure to meet the waiting period or because of an applicable
				  preexisting condition. It does not include a request for payment that is in
				  excess of the applicable contractual limits.
Inforce Data
State Data
Nationwide
Data1
Total Number of Inforce Policies [Certificates] as of
							 December 31s
Claims and Denial Data
State Data
Nationwide
Data1
1
Total Number of Long-Term Care Claims Reported
2
Total Number of Long-Term Care Claims Denied/Not
							 Paid
3
Number of Claims Not Paid due to Preexisting
							 Condition Exclusion
4
Number of Claims Not Paid due to Waiting
							 (Elimination) Period Not Met
5
Net Number of Long-Term Care Claims Denied for
							 Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6
Percentage of Long-Term Care Claims Denied of Those
							 Reported (Line 5 Divided By Line 1)
7
Number of Long-Term Care Claim Denied due to:
8
* Long-Term Care Services Not Covered under the
							 Policy2
9
* Provider/Facility Not Qualified under the
							 Policy3
10
* Benefit Eligibility Criteria Not
Met4
11
* Other
1. The
				nationwide data may be viewed as a more representative and credible indicator
				where the data for claims reported and denied for your state are small in
				number.
2. Example - home health
				care claim filed under a nursing home only policy.
3. Example - a facility that does not meet
				the minimum level of care requirements or the licensing requirements as
				outlined in the policy.
4. Examples
				- a benefit trigger not met, certification by a licensed health care
				practitioner not provided, no plan of care.