reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.55 - Use of Statistics; Jurisdictional Licensing; Status of Insurer

Current through Register Vol. 47, No. 3, July 24, 2024
Advertisements shall be in compliance with 191-subrule
				  15.3(5) and with the following:
(1) An
				advertisement shall specifically identify the Medicare supplement insurance
				policy to which statistics relate and, where statistics are given which are
				applicable to a different policy, the advertisement shall state clearly that
				the data do not relate to the policy being advertised.
(2) An advertisement that is intended to be
				seen or heard beyond the limits of the jurisdiction in which the insurer is
				licensed shall not imply licensing beyond those limits.
(3) An advertisement shall not create the
				impression directly or indirectly that the insurer, the insurer's financial
				condition or status, the insurer's payment of its claims, or the merits,
				desirability or advisability of the insurer's policy forms or kinds of plans of
				insurance are approved, endorsed or accredited by any division or agency of
				this state or of the United States government.
(4) An advertisement shall not imply that
				approval, endorsement or accreditation of policy forms or advertising has been
				granted by any division or agency of this state or of the United States
				government. "Approval" of either policy forms or advertising shall not be used
				by an insurer to imply or state that a governmental agency has endorsed or
				recommended the insurer, its policies, its advertising or its financial
				condition.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.56 - Identity of Insurer

Current through Register Vol. 47, No. 3, July 24, 2024
Advertisements shall be in compliance with 191-subrule
				  15.3(9) and with the following:
(1)
				Advertisements, stationery or envelopes that employ words, letters, initials,
				symbols or other devices are not permitted if they are so similar to those used
				by governmental agencies or other insurers that they may lead the public to
				believe:
a. The advertised coverages are
				somehow provided by or are endorsed by the governmental agencies or the other
				insurers;
b. The advertiser is the
				same as, is connected with or is endorsed by the governmental agencies or the
				other insurers.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.57 - Introductory, Initial or Special Offers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Enrollment periods.
a. An advertisement of an individual policy
				shall not directly or by implication represent that a contract or combination
				of contracts is an introductory, initial or special offer, or that applicants
				will receive substantial advantages not available at a later date, or that the
				offer is available only to a specified group of individuals, unless such
				representation is true. An advertisement shall not contain phrases describing
				an enrollment period as "special," "limited," or similar words or phrases when
				the insurer uses such enrollment periods as the usual method of advertising
				Medicare supplement insurance.
b.
				An enrollment period during which a particular insurance product may be
				purchased on an individual basis shall not be offered within this state unless
				there has been a lapse of not less than six months between the close of the
				immediately preceding enrollment period for the same product and the opening of
				the new enrollment period. The advertisement shall indicate the date by which
				the applicant must mail the application, which shall be not fewer than 10 days
				and not more than 40 days from the date that the enrollment period is
				advertised for the first time. This rule applies to all advertising media,
				e.g., mail, newspapers, electronic mail, Web sites, radio, television,
				magazines and periodicals, used by any one insurer. This rule is not applicable
				to solicitations of employees or members of a particular group or association
				that otherwise would be eligible for group, blanket or franchise insurance. The
				phrase "any one insurer" in this paragraph includes all the affiliated
				companies of a group of insurance companies under common management or control.
				The phrase "a particular insurance product" in this paragraph means an
				insurance policy that provides benefits substantially different from those
				contained in any other policy. Different terms of renewability, an increase or
				decrease in the dollar amounts of benefits, or an increase or decrease in any
				elimination period or waiting period from those available during an enrollment
				period for another policy shall not be sufficient to constitute the product's
				being offered as a different product eligible for concurrent or overlapping
				enrollment periods.
c. This rule
				prohibits any statement or implication to the effect that only a specific
				number of policies will be sold, or that a time is fixed for the discontinuance
				of the sale of the particular policy advertised because of special advantages
				available in the policy, unless either is true.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.58 - Enforcement Procedures-certificate of Compliance

Current through Register Vol. 47, No. 3, July 24, 2024
Each insurer required to file an annual statement which is
				  now or which hereafter becomes subject to the provisions of these rules must
				  file with the insurance division, with the insurer's annual statement, a
				  certificate of compliance executed by an authorized officer of the insurer
				  wherein it is stated that, to the best of the authorized officer's knowledge,
				  information and belief, the advertisements that were disseminated by the
				  insurer during the preceding statement year complied with or were made to
				  comply in all respects with the provisions of these rules and the laws of this
				  state as implemented and interpreted by these rules.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.59 - Filing for Prior Review

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner may, at the commissioner's discretion,
				  require the filing with the insurance division, for review prior to use, of any
				  Medicare supplement insurance advertising material.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.12 - Purpose and Applicability

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				purpose of this chapter is to adopt the new model provisions for coordination
				of benefits (COB) as promulgated by the National Association of Insurance
				Commissioners (NAIC).
(2) This
				division is intended to establish a uniform order of benefit determination
				under which plans pay claims; to reduce duplication of benefits by permitting a
				reduction of the benefits to be paid by plans that, pursuant to rules
				established by this division, do not have to pay benefits first; and to provide
				greater efficiency in the processing of claims when a person is covered under
				more than one plan.
(3) These rules
				apply to all plans that are issued on or after January 25, 2006.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.14 - Use of Model Cob Contract Provision

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Appendix A of this division contains a
				model COB provision for use in contracts. The use of this model COB provision
				is subject to the provisions of subrules 38.14(2) through 38.14(4) and to rule
				38.15(509,514).
(2) Appendix B of
				this division is aplain language description of the COB process that explains
				to the covered person how health plans will implement coordination of benefits.
				Appendix B is not intended to replace or change the provisions that are set
				forth in the contract. The purpose of Appendix B is to explain the process by
				which two or more plans will pay for or provide benefits.
(3) The COB provision contained in the
				appendices to this division do not have to use the specific words and format
				shown in the appendices. Changes may be made to fit the language and style of
				the rest of the contract or to reflect differences among plans that provide
				services, that pay benefits for expenses incurred and that indemnify. No
				substantive changes are permitted.
(4) A COB provision may not be used that
				permits a plan to reduce its benefits on the basis that:
a. Another plan exists and the covered person
				did not enroll in that plan;
b. A
				person is or could have been covered under another plan, except with respect to
				Part B of Medicare; or
c. A person
				has elected an option under another plan providing a lower level of benefits
				than another option that could have been elected.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.15 - Rules for Coordination of Benefits

Current through Register Vol. 47, No. 3, July 24, 2024
When a person is covered by two or more plans, the order of
				  benefit payments shall be determined as follows:
(1)
Primary plans.
The
				primary plan shall pay or provide its benefits as if the secondary plan or
				plans do not exist.
a. If the primary plan is
				a closed panel plan and the secondary plan is not a closed panel plan, the
				secondary plan shall pay or provide benefits as if it were the primary plan
				when a covered person uses a non-panel provider, except for emergency services
				or authorized referrals that are paid or provided by the primary
				plan.
b. When multiple contracts
				providing coordinated coverage are treated as a single plan under this
				division, this subrule applies only to the plan as a whole, and coordination
				among the component contracts is governed by the terms of the contracts. If
				more than one carrier pays or provides benefits under the plan, the carrier
				designated as primary within the plan shall be responsible for the plan's
				compliance with this division.
c.
				If a person is covered by more than one secondary plan, the order of benefit
				determination rules of this division decide the order in which secondary plans
				benefits are determined in relation to each other Each secondary plan shall
				take into consideration the benefits of the primary plan or plans and the
				benefits of any other plan, which, under the rules of this division, has its
				benefits determined before those of that secondary plan.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.16 - Procedure to Be Followed by Secondary Plan to Calculate Benefits and Pay a Claim

Current through Register Vol. 47, No. 3, July 24, 2024
In determining the amount to be paid by the secondary plan on
				  a claim, should the plan wish to coordinate benefits, the secondary plan shall
				  calculate the benefits it would have paid on the claim in the absence of other
				  health care coverage and apply that calculated amount to any allowable expense
				  under its plan that is impaid by the primary plan. The secondary plan may
				  reduce its payment by an amount so that, when combined with the amoimt paid by
				  the primary plan, the total benefits paid or provided by all plans for the
				  claim do not exceed 100 percent of the total allowable expense for that claim.
				  In addition, the secondary plan shall credit to its plan deductible any amoimts
				  it would have credited to its deductible in the absence of other health care
				  coverage.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.17 - Notice to Covered Persons

Current through Register Vol. 47, No. 3, July 24, 2024
A plan shall, in its explanation of benefits provided to
				  covered persons, include the following language: "If you are covered by more
				  than one health benefit plan, you should file all your claims with each
				  plan."
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 38 - Coordination of Benefits › Rule 191-38.18 - Miscellaneous Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				secondary plan that provides benefits in the form of services may recover the
				reasonable cash value of the services from the primary plan, to the extent that
				benefits for the services are covered by the primary plan and have not already
				been paid or provided by the primary plan. Nothing in this subrule shall be
				interpreted to require a plan to reimburse a covered person in cash for the
				value of services provided by a plan that provides benefits in the form of
				services.
(2) Complying and
				noncomplying plans.
a. A plan with order of
				benefit determination provisions that comply with this division (complying
				plan) may coordinate its benefits with a plan that is "excess" or "always
				secondary" or that uses order of benefit determination rules that are
				inconsistent with those contained in this division (noncomplying plan) on the
				following basis:
(1) If the complying plan is
				the primary plan, it shall pay or provide its benefits first;
(2) If the complying plan is the secondary
				plan, it shall pay or provide its benefits first, but the amount of the
				benefits payable shall be determined as if the complying plan were the
				secondary plan. In such a situation, the payment shall be the limit of the
				complying plan's liability; and
(3)
				If the noncomplying plan does not provide the information needed by the
				complying plan to determine the complying plan's benefits within a reasonable
				time after the noncomplying plan is requested to do so, the complying plan
				shall assume that the benefits of the noncomplying plan are identical to its
				own, and shall pay its benefits accordingly. If, within two years of payment,
				the complying plan receives information as to the actual benefits of the
				noncomplying plan, the complying plan shall adjust payments
				accordingly.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement Iowa Code chapter
				  514G, to promote the availability of long-term care insurance coverage, to
				  protect applicants for long-term care insurance, as defined, from unfair or
				  deceptive sales or enrollment practices, to facilitate public understanding and
				  comparison of long-term care insurance coverages, and to facilitate flexibility
				  and innovation in the development of long-term care
				  insurance.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.2 - Authority

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter is issued pursuant to the authority vested in
				  the commissioner under Iowa Code section
				  514G.105
				  in accordance with the procedures set forth in Iowa Code chapter
				  17A.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.3 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
Except as otherwise specifically provided, this chapter
				  applies to all long-term care insurance policies and long-term care coverage
				  arrangements delivered or issued for delivery in this state on or after the
				  effective date hereof, by insurers, fraternal benefit societies, nonprofit
				  health, hospital and medical service corporations, prepaid health plans, health
				  maintenance organizations and all similar organizations.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.5 - Policy Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
No long-term care insurance policy delivered or issued for
				  delivery in this state shall use the terms set forth below, unless the terms
				  are defined in the policy and the definitions satisfy the following
				  requirements:
(1)
"Medicare"
shall be defined as "The Health Insurance for the
				Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then
				Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as
				Enacted by the Eighty-ninth Congress of the United States of America and
				popularly known as the Health Insurance for the Aged Act, as then constituted
				and any later amendments or substitutes thereof," or words of similar
				import.
(2)
"Mental or
				nervous disorder"
shall not be defined to include more than neurosis,
				psychoneurosis, psychopathy, psychosis, or mental or emotional disease or
				disorder.
(3)
Nursing
				care.
a.
"Skilled nursing
				care"
shall not be defined more restrictively than one or more
				professional services performed for the benefit of the insured on a daily
				basis, by or under the supervision of a registered nurse, prescribed by a
				physician, appropriate and consistent with the diagnosis and conditions
				requiring care.
b.
"Intermediate nursing care"
shall not be defined more restrictively
				than care which meets all of the above when professional nursing services are
				delivered on a regular basis but less often than daily.
c.
"Custodial nursing care"
shall not be defined more restrictively than that level of care required to
				assist an individual in activities of daily living when, due to age complicated
				by sickness or injury, such care is required. This level of care can be
				performed by persons without professional skills or training.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.6 - Policy Practices and Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Renewability.
The terms
"guaranteed renewable"
and
"noncancellable"
shall not be used in any individual long-term care insurance policy without
				further explanatory language in accordance with the disclosure requirements of
				this chapter. No such policy issued to an individual shall contain renewal
				provisions other than "guaranteed renewable" or "noncancellable."
a. The term
"guaranteed
				renewable"
may be used only when the insured has the right to continue
				the long-term care insurance in force by the timely payment of premiums and
				when the insurer has no unilateral right to make any change in any provision of
				the policy or rider while the insurance is in force and cannot decline to
				renew. Rates may be revised by the insurer on a class basis.
b. The term
"noncancellable"
may be used only when the insured has the right to continue the long-term care
				insurance in force by the timely payment of premiums during which period the
				insurer has no right to unilaterally make any change in any provision of the
				insurance or in the premium rate.
c. Notwithstanding the provisions in
				191-subrule 36.5(4), long-term care insurance policies may contain a return of
				premium or cash value benefit so long as:
(1)
				The return of premium or cash value benefit is not reduced by an amount greater
				than the aggregate of any claims paid under the policy; and
(2) The insurer demonstrates in its filings
				that the reserve basis for the policies is adequate.
Any advertisement or sales presentation of a long-term care
				  insurance policy with a return of premium or cash value benefit provision shall
				  include a side-by-side comparison of premiums for the same policy with and
				  without the return of premium or cash value benefit provision.
d. The term "level
				premium" may be used only when the insurer does not have the right to change
				the premium.
e. In addition to the
				other requirements of this subrule, a qualified long-term care insurance
				contract shall be guaranteed renewable, within the meaning of Section
				7702B(b)(1)(C) of the Internal Revenue Code of 1986.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.7 - Required Disclosure Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Renewability.
a. Individual long-term care insurance
				policies shall contain a renewability provision. Such provision shall be
				appropriately captioned, shall appear on the first page of the policy, and
				shall clearly state the duration of the term of coverage for which the policy
				is issued and for which it may be renewed. This provision shall not apply to
				policies which do not contain a renewability provision, and under which the
				right to nonrenew is reserved solely to the policyholder.
b. A long-term care insurance policy or
				certificate, other than one in which the insurer does not have the right to
				change the premium, shall include a statement that premium rates may
				change.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.8 - Prohibition Against Postclaims Underwriting

Current through Register Vol. 47, No. 3, July 24, 2024
(1) All applications for long-term care
				insurance policies or certificates except those which are guaranteed issue
				shall contain clear and unambiguous questions designed to ascertain the health
				condition of the applicant.
(2) If
				an application for long-term care insurance contains a question which 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.
If the medications listed in such 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.
(3) Except for
				policies or certificates which are guaranteed issue:
a. The following language shall be set out
				conspicuously and in close conjunction with the applicant's signature block on
				an application for a long-term care insurance policy or certificate:
Caution: If your answers on this application are incorrect or
				  untrue, [company] has the right to deny benefits or rescind your policy.
b. The following language, or
				language substantially similar to the following, shall be set out conspicuously
				on the long-term care insurance policy or certificate at the time of delivery:
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]
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.9 - Minimum Standards for Home Health Care Benefits in Long-term Care Insurance Policies

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				long-term care insurance policy or certificate may not, if it provides benefits
				for home health care services, limit or exclude benefits:
a. By requiring that the insured/claimant
				would need skilled care in a nursing facility if home health care services were
				not provided;
b. By requiring that
				the insured/claimant first or simultaneously receive nursing or therapeutic
				services in a home or commimity setting before home health care services are
				covered;
c. By limiting eligible
				services to services provided by registered nurses or licensed practical
				nurses;
d. 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 the provider's licensure or certification;
e. By requiring that the insured/claimant
				have an acute condition before home health care services are covered;
f. By limiting benefits to services provided
				by Medicare-certified agencies or providers;
g. By excluding coverage for personal care
				services provided by a home health aide;
h. 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;
i. By excluding coverage for adult day care
				services.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.10 - Requirement to Offer Inflation Protection

Current through Register Vol. 47, No. 3, July 24, 2024
(1) 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 offers, 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:
a. Increases
				benefit levels annually in a manner so that the increases are compounded
				annually at a rate not less than 5 percent;
b. 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 5 percent for the period beginning with the
				purchase of the existing benefit and extending until the year in which the
				offer is made; or
c. Covers a
				specified percentage of actual or reasonable charges and does not include a
				maximum specified indemnity amount or limit.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.11 - Requirements for Application Forms and Replacement Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Application
				forms shall include the following questions designed to elicit information
				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 producer, except
				where the coverage is sold without a producer, containing such questions may be
				used. With regard to a replacement policy issued to a group defined by Iowa
				Code section 514G.103(9)
"a,"
the following 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, however, that the certificate holder has been notified of the
				replacement.
a. Do you have another long-term
				care insurance policy or certificate in force (including health care service
				contract, health maintenance organization contract)?
b. Did you have another long-term care
				insurance policy or certificate in force during the last 12 months?
(1) If so, with which company?
(2) If that policy lapsed, when did it
				lapse?
c. Are you
				covered by Medicaid?
d. Do you
				intend to replace any of your medical or health insurance coverage with this
				policy [certificate]?
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.12 - Reserve Standards

Current through Register Vol. 47, No. 3, July 24, 2024
(1) When
				long-term care benefits are provided tiirougli tiie acceleration of benefits
				under group or individual life policies or riders to such policies, policy
				reserves for such benefits shall be determined in accordance with Iowa Code
				section
				50836(3).
"a".
(7) Claim reserves must also be established when such
				policy or rider is in claim status.
Reserves for policies and riders subject to this subrule
				  should be based on the multiple decrement model utilizing all relevant
				  decrements except for volimtary 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 the subrule, 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:
a.
				Definition of insured events;
b.
				Covered long-term care facilities;
c. Existence of home convalescence care
				coverage;
d. Definition of
				facilities;
e. Existence or absence
				of barriers to eligibility;
f.
				Premium waiver provision;
g.
				Renewability;
h. Ability to raise
				premiums;
i. Marketing
				method;
j. Underwriting
				procedures;
k. Claims adjustment
				procedures;
l. Waiting
				period;
m. Maximum
				benefit;
n. Availability of
				eligible facilities;
o. Margins in
				claim costs;
p. Optional nature of
				benefit;
q. Delay in eligibility
				for benefit;
r. Inflation
				protection provisions; and
s.
				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.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.13 - Loss Ratio

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Applicability.
This rule shall apply to all long-term care
				insurance policies or certificates except those covered under rules
				191-3926.
				(5140) and
				191-3928.
				(5140).
(2)
Minimum loss
				ratio.
Benefits under long-term care insurance policies shall be
				deemed reasonable in relation to premiums provided the expected loss ratio is
				at least 60 percent, calculated in a manner which provides for adequate
				reserving of the long-term care insurance risk. In evaluating the expected loss
				ratio, due consideration shall be given to all relevant factors including:
a. Statistical credibility of incurred claims
				experience and earned premiums.
b.
				The period for which rates are computed to provide coverage.
c. Experienced and projected
				trends.
d. Concentration of
				experience within early policy duration.
e. Expected claim fluctuation.
f. Experience refunds, adjustments or
				dividends.
g. Renewability
				features.
h. All appropriate
				expense factors.
i.
				Interest.
j. Experimental nature of
				the coverage.
k. Policy
				reserves.
l. Mix of business by
				risk classification.
m. Product
				features such as long elimination periods, high deductibles and high maximum
				limits.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.14 - Filing Requirement

Current through Register Vol. 47, No. 3, July 24, 2024
Prior to an insurer or similar organization's offering group
				  long-term care insurance to a resident of this state pursuant to Iowa Code
				  section
				  514G.103(9)
"d,"
it shall file with the commissioner evidence that the
				  group policy or certificate thereunder has been approved by a state having
				  statutory or regulatory long-term care insurance requirements substantially
				  similar to those adopted in this state.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.15 - Standards for Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Every
				insurer, health care service plan or other entity marketing long-term care
				insurance coverage in this state, directly or through its producers, shall:
a. Establish marketing procedures to ensure
				that any comparison of policies by its producers or by other producers will be
				fair and accurate.
b. Establish
				marketing procedures to ensure that excessive insurance is not sold or
				issued.
c. Display prominently by
				type, stamp or other appropriate means, on the first page of the outline of
				coverage and policy, the following:
"Notice to buyer: This policy may not cover all of the costs
				  associated with long-term care incurred by the buyer during the period of
				  coverage. The buyer is advised to review carefully all policy
				  limitations."
d. Inquire
				and otherwise make every reasonable effort to identify whether a prospective
				applicant or enrollee for long-term care insurance already has accident and
				sickness or long-term care insurance and the types and amoimts of any such
				insurance.
e. Every insurer or
				entity marketing long-term care insurance shall establish auditable procedures
				for verifying compliance with this subrule.
f. If the state in which the policy or
				certificate is to be delivered or issued for delivery has a senior insurance
				counseling program approved by the commissioner, the insurer shall, at
				solicitation, provide written notice to the prospective policyholder and
				certificate holder that such a program is available and the name, address and
				telephone number of the program.
g.
				For long-term care health insurance policies and certificates, use the terms
				"noncancellable" or "level premium" only when the policy or certificate
				conforms to paragraph 39.6(1)
"b."
h. Provide an explanation of contingent
				benefit upon lapse provided for in 39.29(6)
"c."
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.16 - Suitability

Current through Register Vol. 47, No. 3, July 24, 2024
(1) This rule shall
				not apply to life insurance policies that accelerate benefits for long-term
				care.
(2) Every insurer, health
				care service plan or other entity marketing long-term care insurance (the
				"issuer") shall:
a. 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;
b. Train its producers
				in the use of its suitability standards; and
c. Maintain a copy of its suitability
				standards and make it available for inspection upon request by the
				commissioner
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.17 - Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates

Current through Register Vol. 47, No. 3, July 24, 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.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.19 - Requirement to Deliver Shopper's Guide

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A long-term care insurance shopper's
				guide in the format developed by the National Association of Insurance
				Commissioners, the Blue Cross and Blue Shield Association, the Health Insurance
				Association of America or the senior health insurance information program of
				the insurance division shall be provided to all prospective applicants of a
				long-term care insurance policy or certificate or life insurance policy or
				certificate that includes a long-term care rider
a. In the case of producer solicitations, a
				producer must deliver the shopper's guide to the applicant at the time of
				application.
b. In the case of
				direct response solicitations, the shopper's guide must be presented to the
				applicant at the time the policy is delivered.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.20 - Policy Summary and Delivery of Life Insurance Policies With Long-term Care Riders

Current through Register Vol. 47, No. 3, July 24, 2024
(1) If an
				application for a long-term care insurance contract or certificate is approved,
				the issuer shall deliver the contract or certificate of insurance to the
				applicant no later than 30 days after the date of approval.
(2) At the time of policy delivery, a policy
				summary shall be delivered for an individual life insurance policy which
				provides long-term care benefits within the policy or by rider In the case of
				direct response solicitations, the insurer shall deliver the policy summary
				upon the applicant's request, but regardless of request shall make such
				delivery no later than at the time of policy delivery. In addition to complying
				with all applicable requirements, the summary shall also include:
a. An explanation of how the long-term care
				benefit interacts with other components of the policy, including deductions
				from death benefits;
b. An
				illustration of the amount of benefits, the length of benefit, and the
				guaranteed lifetime benefits, if any, for each covered person;
c. Any exclusions, reductions, and
				limitations on benefits of long-term care;
d. If applicable to the policy type, the
				summary shall also include a disclosure of the effects of exercising other
				rights under the policy, a disclosure of guarantees related to long-term care
				costs of insurance charges, and current and projected maximum lifetime
				benefits; and
e. A statement that
				any long-term care inflation protection option required by rule
				191-3910.
				(514D,514G) is not avaflable under this policy.
The provisions of the policy summary listed above may be
				  incorporated into a basic illustration required to be delivered in accordance
				  with 191-Chapter 14 or into the life insurance policy summary which is required
				  to be delivered in accordance with rule 191-15.4(507B).
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.21 - Reporting Requirement for Long-term Care Benefits Funded Through Life Insurance by Acceleration of the Death Benefit

Current through Register Vol. 47, No. 3, July 24, 2024
Any time a long-term care benefit, funded through life
				  insurance which by the acceleration of the death benefit is in benefit payment
				  status, a monthly report shall be provided to the policyholder The report shall
				  include:
1. Any long-term care
				benefits paid out during the month;
2. An explanation of any changes in the
				policy, e.g., death benefits or cash values, due to long-term care benefits
				being paid out; and
3. The amount
				of long-term care benefits existing or remaining.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.23 - Denial of Claims

Current through Register Vol. 47, No. 3, July 24, 2024
If a claim under a long-term care insurance contract is
				  denied, the issuer shall, within 60 days of the date of a written request by
				  the policyholder or certificate holder, or a representative thereof, provide a
				  written explanation of the reasons for the denial; and make available all
				  information directly related to the denial.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.24 - Incontestability Period

Current through Register Vol. 47, No. 3, July 24, 2024
(1) For a
				policy or certificate that has been in force for less than six months, an
				insurer may rescind a long-term care insurance policy or certificate or deny an
				otherwise valid long-term care insurance claim upon a showing of
				misrepresentation that is material to the acceptance for coverage.
(2) For a policy or certificate that has been
				in force for at least six months but less than two years, an insurer may
				rescind a long-term care insurance policy or certificate or deny an otherwise
				valid long-term care insurance claim upon a showing of misrepresentation that
				is both material to the acceptance for coverage and which pertains to the
				condition for which benefits are sought.
(3) After a policy or certificate has been in
				force for two years, it is not contestable upon the grounds of
				misrepresentation alone; such policy or certificate may be contested only upon
				a showing that the insured knowingly and intentionally misrepresented relevant
				facts relating to the insured's health.
(4) No long-term care insurance policy or
				certificate may be field-issued based on medical or health status. For purposes
				of this subrule, "field-issued" means a policy or certificate issued by a
				producer or a third-party administrator pursuant to the underwriting authority
				granted to the producer or third-party administrator by an insurer
(5) If an insurer has paid benefits under the
				long-term care insurance policy or certificate, the benefit payments may not be
				recovered by the insurer in the event that the policy or certificate is
				rescinded.
(6) In the event of the
				death of the insured, this rule shall not apply to the remaining death benefit
				of a life insurance policy that accelerates benefits for long-term care. In
				this situation, the remaining death benefits under these policies shall be
				governed by Iowa Code section
				50828..
				In all other situations, this rule shall apply to life insurance policies that
				accelerate benefits for long-term care.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.26 - Initial Filing Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Effective date.
This rule applies to any long-term care policy
				issued in this state on or after February 1, 2003.
(2)
Required filing.
An
				insurer shall provide the information listed in this subrule to the
				commissioner pursuant to rule
				191-201.
				(505,509,514A,515,515A,515F) 30 days prior to making a long-term care insurance
				form available for sale.
a. A copy of the
				disclosure documents required in rule
				191-3925.
				(514G); and
b. An actuarial
				certification consisting of at least the following:
(1) A statement that the initial premium rate
				schedule is sufficient to cover anticipated costs under moderately adverse
				experience and that the premium rate schedule is reasonably expected to be
				sustainable over the life of the form with no future premium increases
				anticipated;
(2) A statement that
				the policy design and coverage provided have been reviewed and taken into
				consideration;
(3) A statement that
				the underwriting and claims adjudication processes have been reviewed and taken
				into consideration;
(4) A complete
				description of the basis for contract reserves that are anticipated to be held
				under the form, to include:
1. Sufficient
				detail or sample calculations provided so as to have a complete depiction of
				the reserve amounts to be held;
2.
				A statement that the assumptions used for reserves contain reasonable margins
				for adverse experience;
3. A
				statement that the net valuation premium for renewal years does not increase
				(except for attained-age rating where permitted); and
4. A statement that the difference between
				the gross premium and the net valuation premium for renewal years is sufficient
				to cover expected renewal expenses; or if such a statement cannot be made, a
				complete description of the situations where this does not occur;
* An aggregate distribution of anticipated issues may be used
				  as long as the underlying gross premiums maintain a reasonably consistent
				  relationship;
* If the gross premiums for certain age groups appear to be
				  inconsistent with this requirement, the commissioner may request a
				  demonstration under subrule 39.26(3) based on a standard age distribution;
				  and
(5) A
				statement that the premium rate schedule is not less than the premium rate
				schedule for existing similar policy forms also available from the insurer
				except for reasonable differences attributable to benefits; or a comparison of
				the premium schedules for similar policy forms that are currently available
				from the insurer with an explanation of the differences.