New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.50 - APPENDIX B

Current through Register Vol. 35, No. 13, July 16, 2024
LONG TERM CARE INSURANCE PERSONAL WORKSHEET
People buy long-term care insurance for a variety of reasons. These reasons
						  include to avoid spending assets for long-term care, to make sure there are
						  choices regarding the type of care received, to protect family members from
						  having to pay for care, or to decrease the chances of going on Medicaid.
						  However, long term care insurance can be expensive, and is not appropriate 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 insurance company decide if you should buy this policy.
Premium Information
Policy Form
						  Number(s)_____________________________ 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 increase(s).]
Questions Related to Your Income
How will you pay each years'
						  premiums? ___ 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 were raised, for example, by 20%?] 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%
						  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?
___ From My Income ___ From My Savings\Investments ___ My Family
						  will Pay
Questions Related to Your Savings and Investments
Not
						  counting your home, what is the approximate value of all of your assets
						  (savings and investments)? (check one) ___ Under $20,000 ___ $20-30,000 ___
						  $30-50,000 ___ Over $50,000 How do you expect your assets to change over the
						  next ten years? ___ 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. ___ I acknowledge that the carrier and/or its agent
						  (below) has reviewed this form with me including the premium, premium rate
						  increase history and potential for premium rate 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 the
						  potential for premium rate 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:_______________________________________ Date: _________________________
						  (Applicant) [___ I explained to the applicant the importance of completing this
						  information. Signed:______________________________________
						  Date:__________________________ (Agent) Agent'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 agent has advised me that this
						  policy does not appear to be suitable for me. However, I still want the company
						  to consider my application.] Signed:______________________________________
						  Date:__________________________ (Applicant)
The company may contact you
						  to verify your answers.