New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 15 - LONG-TERM CARE INSURANCE › Section 13.10.15.46 - STANDARD FORMAT FOR OUTLINE OF COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
[Company Name] [Address City & State] [Telephone
						  Number] LONG-TERM CARE INSURANCE OUTLINE OF COVERAGE [Policy Number or Group
						  Master Policy and Certificate Number] [Except for policies or certificates
						  which are guaranteed issue, the following caution statement, or language
						  substantially similar, must appear as follows in the outline of coverage.]
						  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] 1.
						  TYPE OF POLICY. This policy is [an individual policy of insurance] [a group
						  policy which 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 the [POLICY][CERTIFICATE].
						  This [POLICY][CERTIFICATE] is not intended to be a federally tax-qulified
						  long-term care insurance contract under Section 7702B(b) of the Internal
						  Revenue Code of 1986, as amended. Benefits received under this
						  [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 i. 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. ii. [Policies and certificates that are
						  noncancelable shall contain the following statement] RENEWABILITY: THIS POLICY
						  [CERTIFICATE] IS NONCANCELABLE. 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 not
						  such provisions;] 5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS [In bold
						  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 the right to
						  change the premium, and if a right exists, describe clearly and voncisely each
						  circumstance under which thepremium 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
						  Buyers Guide available from the insurance company. A. [For agents] Neither
						  [insert company name] nor its agents 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 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. [Non-institutional
						  benefits, by skill level.] [Any benefit screens must be explained in this
						  section. If these screens differ for different benefits, explanation of the
						  screen should accompany each benefit description. If an attending physician or
						  other specified person must certify a certain level of functional dependency in
						  order to be eligible for benefits, this too must be specified. If activities of
						  daily living (ADLs) are used to measure an insured's need for long-term care,
						  then these qualifying criteria or screens must be explained.] 10. LIMITATIONS
						  AND EXCLUSIONS. Describe: A. Preexisting conditions; B. Non-eligible
						  facilities/provider; C. Non-eligible 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 which limit, exclude, restrict,
						  reduce, delay, or in any other manner operate to qualify payment of the
						  benefits described in (8) 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. 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 which provides preconditions to the
						  availability of policy benefits for such an insured.] 13. PREMIUM. A. State the
						  total annual premium for the policy; B. If the premium varies with an
						  applicants choice among benefit options, indicate the portion of annual premium
						  which corresponds to each benefit option. 14. ADDITIONAL FEATURES. A. Indicate
						  if medical underwriting is used; B. Describe other important features. 15.
						  CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IS 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.