Indiana Administrative Code › Title 760 - DEPARTMENT OF INSURANCE › Article 2 - LONG TERM CARE INSURANCE COVERAGE › Rule 17 - Outline of Coverage › Section 17-1 - Standard

Current through July 10, 2024
Authority: IC
				  27-8-12-7; IC
				  27-8-12-14
Affected: IC
				  27-8-12
Sec. 1.
(a) The
				outline of coverage shall be a free-standing document, using no smaller than
				12-point type.
(b) The outline of
				coverage shall contain no material of an advertising nature.
(c) Text that is capitalized or underscored
				in the standard format outline of coverage may be emphasized by other means
				that 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) The format for the outline of coverage
				shall be as follows:
[COMPANY NAME]
[ADDRESS - CITY AND STATE]
[TELEPHONE NUMBER]
LONG TERM CARE INSURANCE
OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate
				  Number]
[Except for policies, certificates, or subscriber agreements
				  that are guaranteed issue, the following caution statement, or language
				  substantially similar, must appear in the outline of coverage.]
Caution: The issuance of this long term care insurance
				  [policy] [certificate] [subscriber agreement] 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] that 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. 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
Federal Tax Implications of this [policy] [certificate]. 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 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
				noncancellable shall contain the following statement:] RENEWABILITY: THIS
				POLICY [CERTIFICATE] IS NONCANCELLABLE. 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 no such provisions.]
5. TERMS UNDER WHICH THE COMPANY
				MAY CHANGE PREMIUMS.
[In boldface 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.]
(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.]
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 insurance producers] Neither [insert
				company name] nor its insurance 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 (1) 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.]
9. BENEFITS PROVIDED BY
				THIS POLICY.
(a) [Covered services, related
				deductible(s), waiting periods, elimination periods, and benefit
				maximums.]
(b) [Institutional
				benefits, by skill level.]
(c)
				[Noninstitutional 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.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a)
				Preexisting conditions.
(b)
				Noneligible facilities/provider.
(c) Noneligible 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 that 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. 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 no 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.]
13. 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 that provides preconditions to the availability of policy benefits
				  for such an insured.]
14.
				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 that corresponds to each benefit option.]
15. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is
				used.
(b) Describe other important
				features.]
16. CONTACT
				THE STATE SENIOR HEALTH INSURANCE INFORMATION PROGRAM 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.