New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 34 - LONG-TERM CARE INSURANCE › Appendix J

Current through Register Vol. 56, No. 14, July 15, 2024
STATE OF NEW JERSEY
LONG-TERM CARE INSURANCE PARTNERSHIP PROGRAM
POLICY CERTIFICATION FORM
DIRECTIONS: This certification must be completed and submitted with each long-term care policy or certificate that is intended to qualify under the state long-term care insurance partnership program. The certification must be signed by an officer of the company with authority to bind the company. A separate certification must be completed for each policy form.
For newly-submitted policy forms intended to qualify for the partnership program, this certification must be included as part of the policy form filing. With respect to a previously filed form that qualifies for the partnership program, this certification shall be submitted to the Department of Banking and Insurance ("Department") and identify the previously filed form number and date of filing by the Department. If an insurer is filing an endorsement or rider to amend a previously filed form in order to make the form compliant with the partnership program, this certification must be filed with the endorsement or rider filing, and must identify the previously filed form with which the rider or endorsement is intended to be used by form number and filing date.
A long-term care policy or certificate may not be issued in New Jersey as a partnership program policy or certificate unless and until this certification has been submitted to the Department and the policy, certificate, rider or endorsement has been filed for use by the Department.
CERTIFICATION
Under Section 1917(b)(5)(B)(iii) of the Social Security Act ( 42 U.S.C. 1396 p(b)(5)(B)(iii) ), the Commissioner of Banking & Insurance ("Commissioner") may certify that long-term care insurance policies (including certificates issued under a group insurance contract) meet certain consumer protection requirements necessary for a policy to qualify as a partnership policy under the New Jersey Long-Term Care Insurance Partnership Program. These consumer protection requirements are set forth in Section 1917(b)(5)(A) of the Social Security Act ( 42 U.S.C. 1396 p(b)(5)(A) ) and principally include certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners ("NAIC") adopted as of October 2000 (referred to herein as the "2000 NAIC Model Regulation" and "2000 NAIC Model Act", respectively.)
In order to provide the Commissioner with information necessary to provide a certification for policies, this certification form requests information and a certification from the insurance carrier regarding policy forms which will be issued as partnership policies. A separate form must be completed for each policy or certificate form.
Part I. GENERAL INFORMATION
A. Name, address, and NAIC Company Code of insurance carrier:
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
B. Policy form covered by this certification, including the form number and filing date:
-----------------------------------------------------------------------------
A copy of the above policy form filled-in for specimen issue, including any riders and endorsements, shall be provided with this certification.
Part II. QUESTIONS REGARDING APPLICABLE PROVISIONS OF THE 2000 MODEL REGULATION AND 2000 MODEL ACT
Please answer each of the questions below with respect to the policy form identified in Part I above. For purposes of answering the questions below, any provision of the 2000 NAIC Model Regulation or 2000 NAIC Model Act listed below shall be treated as including any other provision of the 2000 NAIC Model Regulation or 2000 NAIC Model Act necessary to implement the provision.
Are the following requirements of the 2000 NAIC Model Regulation met with respect to the policy (including certificates issued under a group insurance contract) intended to be covered under the New Jersey Long-Term Care Insurance Partnership Program that are issued on the policy form identified in Part I above?
Yes
No
N/A
A.
Section 6A (relating to guaranteed renewal or
___
___
___
noncancellability), other than paragraph (5)
thereof, and the requirements of section 6B of
the 2000 NAIC Model Act relating to such section
6A. (11:4-34.4(a), and N.J.S.A.
17B:27E-6a )
Yes
No
N/A
B.
Section 6B (relating to prohibitions on
___
___
___
limitations and exclusions) other than
paragraph (7) thereof. (11:4-34.4(b)  )
Yes
No
N/A
C.
Section 6C (relating to extension of benefits).
___
___
___
(11:4-34.4(c)  )
Yes
No
N/A
D.
Section 6D (relating to continuation or
___
___
___
conversion of coverage). (N.J.A.C. 11:4-34.
4(d))
Yes
No
N/A
E.
Section 6E (relating to discontinuance and
___
___
___
replacement of policies). (N.J.A.C. 11:4-34.
4(e))
Yes
No
N/A
F.
Section 7 (relating to unintentional lapse). (N.
___
___
___
J.A.C. 11:4-34.5 )
Yes
No
N/A
G.
Section 8 (relating to disclosure), other than
___
___
___
sections 8F, 8G, 8H, and 8I thereof. (N.J.A.C.
11:4-34.6(a) through (e) )
Yes
No
N/A
H.
Section 9 (relating to required disclosure of
___
___
___
rating practices to consumer). (N.J.A.C.
11:4-34.7 )
Yes
No
N/A
I.
Section 11 (relating to prohibitions against
___
___
___
post-claims underwriting). (11:4-34.9 )
Yes
No
N/A
J.
Section 12 (relating to minimum standards). (N.J.
___
___
___
A.C. 11:4-34.10 )
Yes
No
N/A
K.
Section 14 (relating to application forms and
___
___
___
replacement coverage). (11:4-34.12 )
Yes
No
N/A
L.
Section 15 (relating to reporting requirements).
___
___
___
(11:4-34.13 )
Yes
No
N/A
M.
Section 23 (relating to standards for marketing),
___
___
___
including inaccurate completion of medical
histories, other than paragraphs (1), (6), and
(9) of section 23C. (11:4-34.21 )
Yes
No
N/A
N.
Section 24 (relating to suitability). (N.J.A.C.
___
___
___
11:4-34.22 )
Yes
No
N/A
O.
Section 25 (relating to prohibition against
___
___
___
preexisting conditions and probationary periods
in replacement policies or certificates). (N.J.
A.C. 11:4-34.23 )
Yes
No
N/A
P.
The provisions of section 26 relating to
___
___
___
contingent nonforfeiture benefits, if the
policyholder declines the offer of a
nonforfeiture provision described in section
7702B(g)(4) of the Internal Revenue Code of
1986 ( 26 U.S.C. 7702 B(g)(4) ). (N.J.A.C. 11:4-34.
24)
Yes
No
N/A
Q.
Section 29 (relating to standard format outline
___
___
___
of coverage). (11:4-34.27 )
Yes
No
N/A
R.
Section 30 (relating to requirement to deliver
___
___
___
shopper's guide). (11:4-34.2 8)
Are the following requirements of the 2000 NAIC Model Act met with respect to the policy (including certificates issued under a group insurance contract) intended to be covered under the New Jersey Long-Term Care Insurance Partnership Program that are issued on the policy form identified in Part I above?
Yes
No
N/A
A.
Section 6C (relating to preexisting conditions)
___
___
___
(N.J.S.A. 17B:27E-6b )
Yes
No
N/A
B.
Section 6D (relating to prior hospitalization).
___
___
___
(N.J.S.A. 17B:27E-6c )
Yes
No
N/A
C.
The provisions of section 8 relating to
___
___
___
contingent nonforfeiture benefits. (N.J.S.A.
17B:27E-8 )
Yes
No
N/A
D.
Section 6F (relating to right to return).
___
___
___
(N.J.S.A. 17B:27E-6d )
Yes
No
N/A
E.
Section 6G (relating to outline of coverage).
___
___
___
(N.J.S.A. 17B:27E-6e )
Yes
No
N/A
F.
Section 6H (relating to requirements for
___
___
___
certificates under group plans). (N.J.S.A.
17B:27E-6f )
Yes
No
N/A
G.
Section 6J (relating to policy summary). (N.J.S.
___
___
___
A. 17B:27E-6g )
Yes
No
N/A
H.
Section 6K (relating to monthly reports on
___
___
___
accelerated death benefits). (N.J.S.A.
17B:27E-6h )
Yes
No
N/A
I.
Section 7 (relating to incontestability period).
___
___
___
(17B:27E-7 )
In order for a policy to be covered under the Qualified Partnership of the State, the answers to all questions above should be "yes" (or "N/A" where all requirements with respect to a provision above are not applicable).
Part III. INFLATION PROTECTION
Yes
No
Does the policy identified in Part I above
___
___
contain the inflation protection of the New
Jersey Long-Term Care Insurance Partnership
Program described in N.J.A.C. 11:4-34.30
Part IV. CERTIFICATION
I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete. I understand that false, inaccurate or incomplete information on this form or accompanying documents may result in disapproval of the policy for use in New Jersey and other administrative sanctions against the insurance carrier.
---------------------------
----------------------------
Date
Signature of Officer
Contact Information
(Please type)
Name of Certifying
Officer:___________________________________________________________________
Title:_____________________________________________________________________
Name of Company
Contact:___________________________________________________________________
(If other than Certifying
Officer)
Mailing
Address:___________________________________________________________________
___________________________________________________________________
Telephone
Number:____________________________________________________________________
Fax
Number:____________________________________________________________________