reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-2 - Applicability and scope

Current through Vol. 41, No. 20, July 1,
				  2024
This Part shall apply to all individual accident and health
					 insurance policies delivered or issued for delivery in this state, on and after
					 the effective date hereof, except it shall not apply to individual policies
					 issued pursuant to a conversion privilege under a policy or contract of group
					 or individual insurance when such group or individual policy or contract
					 includes provisions which are inconsistent with the requirements of this
					 section, nor shall it apply to policies being issued to employees or members as
					 additions to franchise plans in existence on the effective date of this
					 section. The requirements contained in this section shall be in addition to any
					 other applicable regulations previously adopted.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-3 - Policy definitions

Current through Vol. 41, No. 20, July 1,
				  2024
Except as provided in this Part, no individual accident or
					 sickness insurance policy delivered or issued for delivery to any person in
					 this state shall contain definitions respecting the matters set forth below
					 unless such definitions comply with the requirements of this section:
(1)
"One period of confinement"
means consecutive days of in hospital service received as an inpatient, or
				  successive confinements when the insured is discharged from and then re-
				  admitted to the hospital within a period of time not more than 90 days, or
				  three times the maximum number of days of in hospital coverage provided by the
				  policy, to a maximum of 180 days.
(2)
"Hospital"
may be defined in
				  relation to its status, facilities and available services or to refiect its
				  accreditation by the Joint Commission on Accreditation of Hospitals.
(A) The definition of the term "hospital"
				  shall not be more restrictive than one requiring that the hospital:
(i) be an institution operated pursuant to
				  law; and
(ii) be primarily and
				  continuously engaged in providing andoperating, either on its premises or in
				  facilities available to the hospital on a prearranged basis and under the
				  supervision of a staff of fully licensed physicians, medical, diagnostic and
				  major surgical facilities for the medical care and treatment of sick or injured
				  persons on an in-patient basis for which a charge is made; and
(iii) provide 24 hour nursing service by or
				  under the supervision of registered graduate professional nurses
				  (R.N.'s).
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-4 - Prohibited policy provisions

Current through Vol. 41, No. 20,
				  July 1, 2024
(a)
Probationary or waiting period.
Except as provided in
				  365:10-5-3(6),
				  no policy shall contain provisions establishing a probationary or waiting
				  period during which no coverage is provided under the policy, subject to the
				  further exception that a policy may specify a probationary or waiting period
				  not to exceed six (6) months for specified diseases or conditions and losses
				  resulting therefrom, for hernia, disorder of reproduction organs, varicose
				  veins, exception shall not be applicable where such specified diseases or
				  conditions are treated on an emergency basis. Accident policies shall not
				  contain probationary or waiting periods.
(b)
Policy or rider for
				  dividend.
No policy or rider for additional coverage may be issued as a
				  dividend unless an equivalent cash payment is offered to the policyholder as an
				  alternative to such dividend policy or rider. No such dividend policy or rider
				  shall be issued for an initial term of less than 6 months. The initial renewal
				  subsequent to the issuance of any policy or rider as a dividend shall clearly
				  disclose that the policyholder is renewing the coverage that was provided as a
				  dividend for the previous term and that such renewal is optional with the
				  policyholder.
(c)
Pre-existing conditions.
No policy shall exclude coverage for a
				  loss due to a pre-existing condition or a period greater than 12 months
				  following policy issue where the application for such insurance does not seek
				  disclosure of prior illness, disease or physical condition or prior medical
				  care and treatment and such pre-existing condition is not specifically excluded
				  by the terms of the policy.
(d)
Hospital confinement indemnity coverage.
Policies providing
				  hospital confinement indemnity coverage shall not contain provisions excluding
				  coverage because of confinement in a hospital operated by the federal
				  government.
(e)
Policy limits
				  or exclusions, Exceptions.
No policy shall limit or exclude coverage by
				  type of illness, accident, treatment or medical condition, except as follows:
(1) Pre-existing conditions or diseases,
				  except for congenital anomalies of a covered dependent child. This paragraph
				  shall apply to:
(A) policies of accident and
				  health insurance, and
(B) limited
				  benefit insurance policies;
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-8 - Separability provision

Current through Vol. 41, No. 20, July 1,
				  2024
If any provisions of the Part or the application thereof to
					 any person or circumstance is for any reason to be invalid, the remainder of
					 the section and the application of such provision to other persons or
					 circumstances shall not be affected thereby.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 1 - MINIMUM STANDARDS AND BENEFITS FOR ACCIDENT AND HEALTH INSURANCE › Section 365:10-5-9 - Disclosure of reasonable charge determination

Current through
				  Vol. 41, No. 20, July 1, 2024
(a) Any contract or certificate of insurance
				  issued by an insurance company, not-for-profit hospital service and medical
				  indemnity plan, health insurance service organization or preferred provider
				  organization which bases its payment for health care services, procedures, or
				  supplies on a determination of average area charges for health care services,
				  procedures, or supplies shall disclose that information to the contract
				  purchaser and certificate holder at the time that the policy or certificate is
				  delivered.
(b) Average area charge
				  means any determination of a charge for health care services, procedures, or
				  supplies on a basis other than the billed rate or contracted rate of the health
				  care provider. For example, average area charge includes, but is not limited
				  to, the terms customary and reasonable, usually and customary, usual,
				  customary, and reasonable, or other similar terms.
(c) The disclosure shall be located on the
				  first page or in a separate document affixed to the front page of the contract
				  or certificate. The disclosure shall:
(1) Be
				  appropriately captioned and printed in font size at least two (2) points larger
				  than the other text of the policy.
(2) Reference the applicable section of the
				  contract or certificate that specifies how average area charges are determined
				  and provide an example of how this determination will affect the payment for
				  services, procedures, or supplies of a health care provider. This example shall
				  provide an explanation of the liability for charges of the insured that exceed
				  the average area charge.
(3) Advise
				  the insured of the provisions of 36 O.S. §
											6571
				  and provide a point of contact for health care providers to request the
				  information used to determine the average area charge.
(4) Include language advising the insured
				  that noncompliance with 36 O.S. §
											6571
				  should be reported to the Oklahoma Insurance Department.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-20 - Purpose [REVOKED]

Current through Vol. 41, No. 20, July 1,
				  2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-21 - Applicability and scope [REVOKED]

Current through Vol. 41, No. 20,
				  July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-22 - Definitions [REVOKED]

Current through Vol. 41, No. 20, July 1,
				  2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-23 - Policy definitions and terms [REVOKED]

Current through Vol.
				  41, No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-24 - Prohibited policy provisions [REVOKED]

Current through Vol. 41,
				  No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-25 - Minimum benefit standards [REVOKED]

Current through Vol. 41,
				  No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-26 - Standards for claims payment [REVOKED]

Current through Vol. 41,
				  No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-27 - Loss ratio standards [REVOKED]

Current through Vol. 41, No. 20,
				  July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-28 - Filing requirements for out-of-state group policies [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-29 - Prohibited compensation for replacement with the same company [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-30 - Required disclosure provisions [REVOKED]

Current through Vol.
				  41, No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-31 - Requirements for replacement [REVOKED]

Current through Vol. 41, No.
				  20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-32 - Filing requirements for advertising [REVOKED]

Current through
				  Vol. 41, No. 20, July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 3 - MINIMUM STANDARDS AND BENEFITS FOR MEDICARE SUPPLEMENT POLICIES [Revoked] › Section 365:10-5-33 - Seperability provision [REVOKED]

Current through Vol. 41, No. 20,
				  July 1, 2024
Revoked at 10 Ok Reg
					 1475, eff 5-1-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-40 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Part is to implement 36 O.S. §
										4421 et
					 seq., to promote the public interest, 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 insurance coverages, and to
					 facilitate flexibility and innovation in the development of long-term care
					 insurance.
Amended at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Amended at 10 Ok Reg 3033, eff
					 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-40.1 - Applicability and scope [EXPIRED]

Current through Vol. 41, No. 20,
				  July 1, 2024
Added at 10 Ok Reg
					 397, eff 11-12-92 through 7-14-93
					 (emergency)1
1This emergency action expired
					 without being superseded by a permanent action. Upon expiration of an emergency
					 action enacting a new Section, the Section is no longer effective. Therefore,
					 on 7-15-93 (after the 7-14-93 expiration of the emergency action), Section
					 365:10-5-40.1 was no longer effective. For the official text of the emergency
					 rule that was in effect from 11-12-92 through 7-14-93, see 10 Ok Reg
					 397.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-41 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
For the purpose of this Part, the terms "long-term care
					 insurance", "applicant", "certificate", "group long-term care insurance", and
					 "policy" shall have the meanings set forth in section 4424 of the Long-term
					 Care Insurance Act.
Amended at 10 Ok Reg
					 3033, eff 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-41.1 - Terms under which the policy [certificate] may be continued in force or discontinued [REVOKED]

Current through Vol. 41, No. 20, July 1,
				  2024
Added at 10 Ok Reg
					 3033, eff 7-15-93; Revoked at 10 Ok Reg 4231, eff 7-15-93 (emergency); Revoked
					 at 10 Ok Reg 1843, eff 5-15-94
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-41.2 - Applicability and scope

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Except as
				  otherwise specifically provided, this Part applies to all long-term care
				  insurance policies delivered or issued for delivery in this state on or after
				  the effective date hereof, by:
(1)
				  insurers;
(2) fraternal benefit
				  societies;
(3) nonprofit health,
				  hospital and medical service corporations;
(4) prepaid health plans;
(5) health maintenance organizations;
				  and
(6) all similar
				  organizations.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-43 - Policy practices and provisions

Current through Vol. 41, No.
				  20, July 1, 2024
(a)
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 O.A.C.
				  365:10-5-44.
(1) No such policy issued to an individual
				  shall contain renewal provisions other than "guaranteed renewable" or
				  "noncancellable".
(2) 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, except that rates may be revised by the insurer on a class
				  basis.
(3) 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.
(4) The term "level premium" may only be used
				  when the insurer does not have the right to change the premium.
(5) In addition to the other requirements of
				  this subsection, 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, as amended.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-44.1 - Prohibition against post-claims underwriting

Current through Vol.
				  41, No. 20, July 1, 2024
(a)
Application question regarding
				  health condition.
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.
(b)
Application
				  question regarding prescriptions.
(1)
				  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.
(2) 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.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-44.2 - Minimum standards for home health and community care benefits in long-term care insurance policies

Current through Vol. 41, No. 20,
				  July 1, 2024
(a)
Home health care benefit standards.
A long-term care insurance
				  policy or certificate shall not, if it provides benefits for home health care
				  or community care services, limit or exclude benefits:
(1) By requiring that the insured/claimant
				  would need care in a skilled nursing facility if home health care services were
				  not provided;
(2) By requiring that
				  the insured/claimant first or simultaneously receive nursing and/or therapeutic
				  services in a home, community, or institutional setting before home health care
				  services are covered;
(3) By
				  limiting eligible services to services provided by registered nurses or
				  licensed practical nurses;
(4) 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 his or her licensure or
				  certification.
(5) By excluding
				  coverage for personal care services provided by a home health aide.
(6) 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.
(7) By requiring that the insured/claimant
				  have an acute condition before home health care services are covered;
(8) By limiting benefits to services provided
				  by Medicare-certified agencies or providers.
(9) By excluding coverage for adult day care
				  services.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-44.3 - Requirement to offer inflation protection

Current through Vol. 41,
				  No. 20, July 1, 2024
(a)
Inflation protection option.
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 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:
(1) Increases benefit levels
				  annually in a manner so that the increases are compounded annually at a rate
				  not less than five percent (5%);
(2) 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 five percent (5%) for the period beginning with
				  the purchase of the existing benefit and extending until the year in which the
				  offer is made; or
(3) Covers a
				  specified percentage of actual or reasonable charges and does not include a
				  maximum specified indemnity amount or limit.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-44.4 - Required disclosure of rating practices to consumers

Current
				  through Vol. 41, No. 20, July 1, 2024
(a) This section shall apply as follows:
(1) Except as provided in Paragraph (2), this
				  section applies to any long-term care policy or certificate issued in this
				  state on or after November 1, 2001.
(2) For certificates issued on or after the
				  effective date of this amended regulation under a group long-term care
				  insurance policy as defined in 36 O.S. §
											4424(4)(a),
				  which policy was in force at the time this amended regulation became effective,
				  the provisions of this section shall apply on the policy anniversary following
				  November 1, 2002.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-44.5 - Initial filing requirements

Current through Vol. 41, No. 20,
				  July 1, 2024
(a) This
				  section applies to any long-term care policy issued in this state on or after
				  November 1, 2001.
(b) An insurer
				  shall provide the information listed in this subsection to the commissioner 60
				  days prior to making a long-term care insurance form available for sale.
(1) A copy of the disclosure documents
				  required in OAC
				  365:10-5-44.4;
				  and
(2) An actuarial certification
				  consisting of at least the following:
(A) 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;
(B) A statement that the policy design and
				  coverage provided have been reviewed and taken into consideration;
(C) A statement that the underwriting and
				  claims adjudication processes have been reviewed and taken into
				  consideration;
(D) A complete
				  description of the basis for contract reserves that are anticipated to be held
				  under the form, to include:
(i) Sufficient
				  detail or sample calculations provided so as to have a complete depiction of
				  the reserve amounts to be held;
(ii) A statement that the assumptions used
				  for reserves contain reasonable margins for adverse experience;
(iii) A statement that the net valuation
				  premium for renewal years does not increase (except for attained-age rating
				  where permitted); and
(iv) 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;
(I) An aggregate
				  distribution of anticipated issues may be used as long as the underlying gross
				  premiums maintain a reasonably consistent relationship;
(II) If the gross premiums for certain age
				  groups appear to be inconsistent with this requirement, the commissioner may
				  request a demonstration under Subsection (c) based on a standard age
				  distribution; and
(E)
Premium rate schedule.
(i) 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
(ii) A
				  comparison of the premium schedules for similar policy forms that are currently
				  available from the insurer with an explanation of the differences.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-45 - Requirements for application forms and for replacement coverage

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application form
				  requirements.
Application forms shall include the following questions
				  designed to elicit information as to 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 agent, except where the coverage is sold without an
				  agent, containing such questions may be used. With regard to a replacement
				  policy issued to a group defined by 36 O.S. §
										4424(4)(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 certificateholder has
				  been notified of the replacement.
(1) Do you
				  have another long-term care insurance policy or certificate in force (including
				  health care service contract, health maintenance organization
				  contract)?
(2) Did you have another
				  long-term care insurance policy or certificate in force during the last twelve
				  (12) months?
(A) If so, with which
				  company?
(B) If that policy lapsed,
				  when did it lapse?
(3)
				  Are you covered by Medicaid?
(4) Do
				  you intend to replace any of your medical or health insurance coverage with
				  this policy [certificate]?
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-45.1 - Reporting requirements

Current through Vol. 41, No. 20, July 1,
				  2024
(a) Every insurer
				  shall maintain records for each agent of that agent's amount of replacement
				  sales as a percent of the agent's total annual sales and the amount of lapses
				  of long-term care insurance policies sold by the agent as a percent of the
				  agent's total annual sales.
(b)
				  Each insurer shall report annually by June 30 the ten percent (10%) of its
				  agents with the greatest percentages of lapses and replacements as measured by
				  (a) of this section.
(c) Reported
				  replacement and lapse rates do not alone constitute a violation of insurance
				  laws or necessarily imply wrongdoing. The reports are for the purpose of
				  reviewing more closely agent activities regarding the sale of long-term care
				  insurance.
(d) Every insurer shall
				  report annually by June 30 the number of lapsed policies as a percent of its
				  total annual sales and as a percent of its total number of policies in force as
				  of the end of the preceding calendar year.
(e) Every insurer shall report annually by
				  June 30 the number of replacement policies sold as a percent of its total
				  annual sales and as a percent of its total number of policies in force as of
				  the preceding calendar year.
(f)
				  Every insurer shall report annually by June 30, for qualified long-term care
				  insurance contracts, the number of claims denied for each class of business,
				  expressed as a percentage of claims denied. An insurer shall use the form in
				  Appendix CC to comply with this provision.
(g) For purposes of this section:
(1) Policy means only long-term care
				  insurance;
(2) Subject to paragraph
				  3 of this subsection, claim means a request for payment of benefits under an in
				  force policy regardless of whether the benefit claimed is covered under the
				  policy or any terms or conditions of the policy have been met;
(3) Denied means the insurer refused to pay a
				  claim for any reason other than for claims not paid for failure to meet the
				  waiting period or because of an applicable preexisting condition; and
(4) Report means on a statewide
				  basis.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-45.2 - Licensing

Current through Vol. 41, No. 20, July 1, 2024
No agent is authorized to market, sell, solicit or
					 otherwise contact any person for the purpose of marketing long-term care
					 insurance except as authorized by the Oklahoma Producer Licensing Act, 36 O.S.
					 §
										1435.1, et
					 seq.
Added at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Added at 10 Ok Reg 3033, eff 7-15-93; Amended at
					 26 Ok Reg 1529, eff 7-14-09
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-45.3 - Discretionary powers of Commissioner

Current through Vol. 41, No.
				  20, July 1, 2024
The Commissioner may upon written request and after an
					 administrative hearing, issue an order to modify or suspend a specific
					 provision or provisions of this Part with respect to a specific long-term care
					 insurance policy or certificate upon a written finding that:
(1) The modification or suspension would be
				  in the best interest of the insureds; and
(2) The purposes to be achieved could not be
				  effectively or efficiently achieved without the modification or suspension;
				  and
(3) At least one of the
				  following applies:
(A) The modification or
				  suspension is necessary to the development of an innovative and reasonable
				  approach for insuring long-term care; or
(B) The policy or certificate is to be issued
				  to residents of a life care or continuing care retirement community or some
				  other residential community for the elderly and the modification or suspension
				  is reasonably related to the special needs or nature of such a community;
				  or
(C) The modification or
				  suspension is necessary to permit long-term care insurance to be sold as part
				  of, or in conjunction with, another insurance product.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-46 - Reserve standards

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Benefits
				  provided through acceleration of benefits.
(1) When long-term care benefits are provided
				  through the acceleration of benefits under group or individual life policies or
				  riders to such, policy reserves for such benefits shall be determined in
				  accordance with such tables as may be approved by the Commissioner. Claim
				  reserves must also be established in the case when such policy or rider is in
				  claim status.
(2) Reserves for
				  policies and riders subject to this subsection should be based on the multiple
				  decrement model utilizing all relevant decrement except for voluntary
				  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.
(3) In the development and calculation of
				  reserves for policies and riders subject to this subsection, 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.
(4) Any applicable valuation morbidity table
				  shall be certified as appropriate as a statutory valuation table by a member of
				  the American Academy of Actuaries.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-47 - Loss ratio

Current through Vol. 41, No. 20, July 1,
				  2024
(a) This section
				  shall apply to all long-term care insurance policies and certificates except
				  those covered under OAC
				  365:10-5-44.5
				  and
				  365:10-5-47.1.
(b) Benefits under long-term care insurance
				  policies shall be deemed reasonable in relation to premiums provided the
				  expected loss ratio is at least sixty percent (60%), 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:
(1) Statistical
				  credibility of incurred claims experience and earned premiums;
(2) The period for which rates are computed
				  to provide coverage;
(3)
				  Experienced and projected trends;
(4) Concentration of experience within early
				  policy duration;
(5) Expected claim
				  fluctuation;
(6) Experience
				  refunds, adjustments or dividends;
(7) Renewability features;
(8) All appropriate expense
				  factors;
(9) Interest;
(10) Experimental nature of the
				  coverage;
(11) Policy
				  reserves;
(12) Mix of business by
				  risk classifications; and
(13)
				  Product features such as long elimination periods, high deductibles and high
				  maximum limits.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-47.1 - Premium rate schedule increases

Current through Vol. 41, No.
				  20, July 1, 2024
(a)
				  This section shall apply as follows:
(1)
				  Except as provided in Paragraph (2), this section applies to any long-term care
				  policy or certificate issued in this state on or after November 1,
				  2001.
(2) For certificates issued
				  on or after the effective date of this amended regulation under a group
				  long-term care insurance policy as defined in 36 O.S. §
											4424(4)(a),
				  which policy was in force at the time this amended regulation became effective,
				  the provisions of this section shall apply on the policy anniversary following
				  November 1, 2002.
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48 - Filing requirement

Current through Vol. 41, No. 20, July 1,
				  2024
Prior to an insurer or similar organization offering group
					 or individual long-term care insurance to a resident of this state pursuant to
					 36 O.S. §
										4425 to the
					 Long-term Care Insurance Act, it shall receive prior approval by the
					 Commissioner of all group and individual policies or certificates intended to
					 be sold or issued to residents of this state.
Amended at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Amended at 10 Ok Reg 3033, eff
					 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48.1 - Filing requirements for advertising

Current through Vol. 41,
				  No. 20, July 1, 2024
(a)
				  Every insurer, health care service plan or other entity providing long-term
				  care insurance or benefits in this state shall provide a copy of any long-term
				  care insurance advertisement intended for use in this state whether through
				  written, radio or television medium to the Insurance Commissioner of this
				  state. In addition, all advertisements shall be retained by the insurer, health
				  care service plan or other entity for at least three (3) years from the date
				  the advertisement was first used.
(b) The Commissioner may exempt from the
				  requirements in (a) of this section any advertising form or material when in
				  the Commissioner's opinion, the requirement may not be reasonably
				  applied.
Added at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Added at 10 Ok Reg 3033, eff
					 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48.2 - Standards for marketing

Current through Vol. 41, No. 20, July 1,
				  2024
(a)
Marketing
				  requirements.
Every insurer, health care service plan or other entity
				  marketing long-term care insurance coverage in this state, directly or through
				  its producers, shall:
(1) Establish marketing
				  procedures to assure that any comparison of policies by its agents or other
				  producers will be fair and accurate.
(2) Establish marketing procedures to assure
				  excessive insurance is not sold or issued.
(3) 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.
(4) 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 amounts of any such
				  insurance.
(5) Establish audible
				  procedures for verifying compliance with this subsection (a).
(6) 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, provide written notice to the
				  prospective policyholder and certificateholder, at solicitation, that such a
				  program is available and the name, address and telephone number of the
				  program.
(7) For long-term care
				  health insurance policies and certificates, use the terms "noncancellable" or
				  "level premium" only when the policy or certificate conforms to
				  365:10-5-43(a)(3).
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48.3 - Appropriateness of recommended purchase

Current through Vol. 41, No.
				  20, July 1, 2024
In recommending the purchase or replacement of any
					 long-term care insurance policy or certificate an agent shall make reasonable
					 efforts to determine the appropriateness of a recommended purchase or
					 replacement.
Added at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Added at 10 Ok Reg 3033, eff
					 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48.4 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Vol. 41, No. 20, July
				  1, 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.
Added at 10 Ok Reg
					 397, eff 11-12-92 (emergency); Added at 10 Ok Reg 3033, eff
					 7-15-93
Oklahoma Administrative Code › Title 365 - Insurance Department › Chapter 10 - Life, Accident and Health › Subchapter 5 - Minimum Standards; Contract Guidelines › Part 5 - LONG-TERM CARE INSURANCE › Section 365:10-5-48.5 - Suitability

Current through Vol. 41, No. 20, July 1, 2024
(a) This section shall not apply to life
				  insurance policies that accelerate benefits for long-term care.
(b) Every insurer, health care service plan
				  or other entity marketing long-term care insurance (the "issuer") shall:
(1) 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;
(2) Train its agents in the use of its
				  suitability standards; and
(3)
				  Maintain a copy of its suitability standards and make them available for
				  inspection upon request by the commissioner.