reglab/statecodes huggingface dataset:
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-10 - Minimum standards for home health and community care benefits in long-term care insurance policies

Current through Supplement No. 393, July, 2024
1. 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:
a. By requiring that the insured or
				claimant would need care in a skilled nursing facility if home health care
				services were not provided;
b. By
				requiring that the insured or claimant first or simultaneously receive nursing
				or therapeutic services, or both, in a home, community, or institutional
				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 worker's licensure or certification;
e. By excluding coverage for personal care
				services provided by a home health aide;
f. 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;
g. By requiring that the insured or claimant
				have an acute condition before home health care services are covered;
h. By limiting benefits to
				services provided by medicare-certified agencies or providers; or
i. By excluding coverage for adult day care
				services.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-11 - Requirement to offer inflation protection

Current through Supplement No. 393, July, 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 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 five 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 five
				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.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-12 - Requirements for application forms and replacement coverage

Current through Supplement No. 393, July, 2024
1. 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 when the coverage is
				sold without an agent, containing the questions may be used. With regard to a
				replacement policy issued to a group defined by subdivision a of subsection 3
				of North Dakota Century Code section 26.1-45-01, 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 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 twelve 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]?
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-13 - Reporting requirements

Current through Supplement No. 393, July, 2024
1. Every
				insurer shall maintain records for each agent of that agent's amount of
				replacement sales as a percentage of the agent's total annual sales and the
				amount of lapses of long-term care insurance policies sold by the agent as a
				percentage of the agent's total annual sales.
2. Every insurer shall report annually by
				June thirtieth the ten percent of its agents with the greatest percentages of
				lapses and replacements as measured by subsection 1. (Appendix G)
3. 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.
4. Every insurer shall report annually by
				June thirtieth the number of lapsed policies as a percentage of its total
				annual sales and as a percentage of its total number of policies in force as of
				the end of the preceding calendar year. (Appendix G)
5. Every insurer shall report annually by
				June thirtieth the number of replacement policies sold as a percentage of its
				total annual sales and as a percentage of its total number of policies in force
				as of the preceding calendar year. (Appendix G)
6. Every insurer shall report annually by
				June thirtieth, for qualified long-term care insurance contracts, the number of
				claims denied for each class of business, expressed as a percentage of claims
				denied. (Appendix E)
7. For
				purposes of this section:
a. Subject to
				subdivision c, "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;
b. "Denied" means the insurer refuses 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;
c. "Policy" means only long-term care
				insurance; and
d. "Report" means
				on a statewide basis.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-14 - Licensing

Current through Supplement No. 393, July, 2024
A producer is not authorized to sell, solicit, or negotiate
				  with respect to long-term care insurance except as authorized by chapter
				  45-02-02 and North Dakota Century Code chapter 26.1-26.
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-45
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-15 - Discretionary powers of commissioner

Current through Supplement No. 393, July, 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 chapter 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;
2. The purposes to be achieved could not be
				effectively or efficiently achieved without the modification or suspension; and
3.
a.The modification or suspension is necessary to the
				development of an innovative and reasonable approach for insuring long-term
				care;
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.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-16 - Reserve standards

Current through Supplement No. 393, July, 2024
1. When long-term
				care benefits are provided through the acceleration of benefits under group or
				individual life policies or riders to such policies, policy reserves for the
				benefits shall be determined in accordance with North Dakota Century Code
				section 26.1-35-02. Claim reserves shall also be established in the case when
				the policy or rider is in claim status.
Reserves for policies and riders subject to this subsection
				  should be based on the multiple decrement model utilizing all relevant
				  decrements 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.
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.
Any applicable valuation morbidity table shall be certified
				  as appropriate as a statutory valuation table by a member of the American
				  academy of actuaries.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-17 - Life insurance long-term care benefits

Current through Supplement No. 393, July, 2024
1. A life insurance policy that funds
				long-term care benefits entirely by accelerating the death benefit is
				considered to provide reasonable benefits in relation to premiums paid, if the
				policy complies with all of the following provisions:
a. The interest credited internally to
				determine cash value accumulations, including long-term care, if any, are
				guaranteed not to be less than the minimum guaranteed interest rate for cash
				value accumulations without long-term care set forth in the policy;
b. The portion of the policy that provides
				life insurance benefits meets the nonforfeiture requirements of North Dakota
				Century Code sections 26.1-33-18 through 26.1-33-28;
c. The policy meets the disclosure
				requirements of subsections 4, 5, and 6 of North Dakota Century Code section
				26.1-45-09;
d. Any policy
				illustration that meets the applicable requirements of the national association
				of insurance commissioners life insurance illustrations model regulation;
				and
e. An actuarial memorandum is
				filed with the insurance department that includes:
(1) A description of the basis on which the
				long-term care rates were determined;
(2) A description of the basis for the
				reserves;
(3) A summary of the type
				of policy, benefits, renewability, general marketing method, and limits on ages
				of issuance;
(4) A description and
				a table of each actuarial assumption used. For expenses, an insurer must
				include a percentage of premium dollars per policy and dollars per unit of
				benefits, if any;
(5) A description
				and a table of the anticipated policy reserves and additional reserves to be
				held in each future year for active lives;
(6) The estimated average annual premium per
				policy and the average issue age;
(7) A statement as to whether underwriting is
				performed at the time of application. The statement shall indicate whether
				underwriting is used and, if used, the statement shall include a description of
				the type or types of underwriting used, such as medical underwriting or
				functional assessment underwriting. Concerning a group policy, the statement
				shall indicate whether the enrollee or any dependent will be underwritten and
				when underwriting occurs; and
(8) A
				description of the effect of the long-term care policy provision on the
				required premiums, nonforfeiture values, and reserves on the underlying life
				insurance policy, both for active lives and those in long-term care claim
				status.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-18 - Premium rate schedule increases

Current through Supplement No. 393, July, 2024
1. This
				section shall apply as follows:
a. Except as
				provided in subdivision b, this section applies to any long-term care policy or
				certificate issued in this state on or after September 1, 2004.
b. For certificates issued on or after the
				effective date of this amended regulation under a group long-term care
				insurance policy as defined in subdivision a of subsection 3 of North Dakota
				Century Code section 26.1-45-01, 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 March 1, 2005.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-19 - Filing requirement

Current through Supplement No. 393, July, 2024
Prior to an insurer or similar organization offering group
				  long-term care insurance to a resident of this state pursuant to North Dakota
				  Century Code section 26.1-45-03, 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.
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-45
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-20 - Filing requirements for advertising

Current through Supplement No. 393, July, 2024
1. 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 for review or approval by the commissioner
				to the extent it may be required under state law. In addition, all
				advertisements shall be retained by the insurer, health care service plan, or
				other entity for at least three years from the date the advertisement was first
				used.
2. The commissioner may
				exempt from these requirements any advertising form or material when, in the
				commissioner's opinion, this requirement may not be reasonably applied.
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-45
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-21 - Standards for marketing

Current through Supplement No. 393, July, 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 and agent
				training requirements to assure that:
(1) Any
				marketing activities, including any comparison of policies, by its agents or
				other producers will be fair and accurate; and
(2) Excessive insurance is not sold or
				issued.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-22 - Suitability

Current through Supplement No. 393, July, 2024
1. This section 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 agents in the use of its
				suitability standards; and
c.
				Maintain copies of its suitability standards and make them available for
				inspection upon request by the commissioner.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-23 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Supplement No. 393, July, 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.
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-45
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-24 - Nonforfeiture benefit requirement

Current through Supplement No. 393, July, 2024
1. This
				section does not apply to life insurance policies or riders containing
				accelerated long-term care benefits.
2. To comply with the requirement to offer a
				nonforfeiture benefit pursuant to the provisions of North Dakota Century Code
				section 26.1-45-14:
a. A policy or
				certificate offered with nonforfeiture benefits shall have coverage elements,
				eligibility, benefit triggers, and benefit length that are the same as coverage
				to be issued without nonforfeiture benefits. The nonforfeiture benefit included
				in the offer shall be the benefit described in subsection 5; and
b. The offer shall be in writing if the
				nonforfeiture benefit is not otherwise described in the outline of coverage or
				other materials given to the prospective policyholder.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-25 - Standards for benefit triggers

Current through Supplement No. 393, July, 2024
1. A
				long-term care insurance policy shall condition the payment of benefits on a
				determination of the insured's ability to perform activities of daily living
				and on cognitive impairment. Eligibility for the payment of benefits shall not
				be more restrictive than requiring either a deficiency in the ability to
				perform not more than three of the activities of daily living or the presence
				of cognitive impairment.
2.
a. Activities of daily living shall include
				at least the following as defined in section
				45-06-05.1-03 and in the policy:
(1) Bathing;
(2) Continence;
(3) Dressing;
(4) Eating;
(5) Toileting; and
(6) Transferring; and
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-26 - Additional standards for benefit triggers for qualified long-term care insurance contracts

Current through Supplement No. 393, July, 2024
1. For purposes of
				this section, the following definitions apply:
a.
(1)
				"Chronically ill individual" has the meaning prescribed for this term by
				section 7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under
				this provision, a chronically ill individual means any individual who has been
				certified by a licensed health care practitioner as:
(a) Being unable to perform, without
				substantial assistance from another individual, at least two activities of
				daily living for a period of at least ninety days due to a loss of functional
				capacity; or
(b) Requiring
				substantial supervision to protect the individual from threats to health and
				safety due to severe cognitive impairment.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-28 - Requirement to deliver shopper's guide

Current through Supplement No. 393, July, 2024
1.
				A long-term care insurance shopper's guide in the format developed by the
				national association of insurance commissioners, or a guide developed or
				approved by the commissioner, shall be provided to all prospective applicants
				of a long-term care insurance policy or certificate.
a. In the case of agent solicitations, an
				agent must deliver the shopper's guide prior to the presentation of an
				application or enrollment form.
b.
				In the case of direct response solicitations, the shopper's guide must be
				presented in conjunction with any application or enrollment form.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 45-06-05.1-29 - Penalties

Current through Supplement No. 393, July, 2024
In addition to any other penalties provided by the laws of
				  this state, any insurer and any agent found to have violated any requirement of
				  this state relating to the regulation of long-term care insurance or the
				  marketing of such insurance shall be subject to a fine of up to three times the
				  amount of any commissions paid for each policy involved in the violation or up
				  to ten thousand dollars, whichever is greater.
General Authority: NDCC 28-32-02
Law Implemented: NDCC
					 26.1-45
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix A - Rescission Reporting Form

Current through Supplement No. 393, July, 2024
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
				  FOR THE STATE OF __________________ FOR THE REPORTING YEAR 20[ ]
Company Name: _____________________________________
Address: ___________________________________________
_____________________________________________
Telephone Number:
				  ______________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of
				  long-term care insurance policies or certificates. Those rescissions
				  voluntarily effectuated by an insured are not required to be included in this
				  report. Please furnish one form per rescission.
Policy Form #
Policy and Certificate
						  #
Name of Insured
Date of Policy Issuance
Date/s
						  Claim/s Submitted
Date of Rescission
Detailed reason for
				  rescission:__________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
____________________________
Signature
____________________________
Name and title (please type)
____________________________
Date
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix D - Response Letter

Current through Supplement No. 393, July, 2024
Long-Term Care Insurance Suitability
				  Letter
Dear [Applicant]:
Your recent application for long-term care insurance
				  included a "personal worksheet", which asked questions about your finances and
				  your reasons for buying long-term care insurance. For your protection, state
				  law requires us to consider this information when we review your application,
				  to avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not
				  meet your financial needs. We suggest that you review the information provided
				  along with your application, including the booklet "Shopper's Guide to
				  Long-Term Care Insurance" and the page titled "Things You Should Know Before
				  Buying Long-Term Care Insurance". Your state insurance department also has
				  information about long-term care insurance and may be able to refer you to a
				  counselor free of charge who can help you decide whether to buy this
				  policy.]
[You chose not to provide any financial information for us
				  to review.]
We have suspended our final review of your application. If,
				  after careful consideration, you still believe this policy is what you want,
				  check the appropriate box below and return this letter to us within the next 60
				  days. We will then continue reviewing your application and issue a policy if
				  you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				  close your file and not issue you a policy. You should understand that you will
				  not have any coverage until we hear back from you, approve your application,
				  and issue you a policy.
Please check one box and return in the enclosed
				  envelope.
[ ]
Yes,
[although my worksheet indicates that
				  long-term care insurance may not be a suitable purchase,] I wish to purchase
				  this coverage. Please resume review of my application.
[ ]
No.
I have decided not to buy a policy at
				  this time.
__________________________ ________________________
APPLICANT'S SIGNATURE DATE
Please return to [issuer] at [address] by [date].
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix E - Sample Claims Denial Format

Current through Supplement No. 393, July, 2024
Claims Denial Reporting Form Long-Term Care
				  Insurance
For the State of _______________________________
For the Reporting Year of ______________________
Company Name: ______________________________ Due: June 30
				  annually
Company Address:
				  ______________________________________________
______________________________________________________________
Company NAIC Number:
				  __________________________________________
Contact Person: ___________________ Telephone Number:
				  ________________
Line of Business: Individual Group
Instructions
The purpose of this form is to report all long-term care
				  claim denials under in-force long-term care insurance policies. Indicate the
				  manner of reporting by checking one of the boxes below:
[] Per Claimant - Counts each individual who makes one or a
				  series of claim requests.
[] Per Transaction - Counts each claim payment
				  request.
"Denied" means a claim that is not paid for any reason other
				  than for claims not paid for failure to meet the waiting period or because of
				  an applicable pre-existing condition. It does not include a request for payment
				  that is in excess of the applicable contractual limits.
In-force Data
State Data
Nationwide
							 Data1
1
Total Number of In-force Policies [Certificates] as
							 of December 31st
Claims and Denial Data
State Data
Nationwide
							 Data1
1
Total Number of Long-Term Care Claims
							 Reported
2
Total Number of Long-Term Care Claims
							 Denied/Not Paid
3
Number of Claims Not Paid Due to
							 Preexisting Condition Exclusion
4
Number of Claims Not Paid Due to Waiting
							 (Elimination) Period Not Met
5
Net Number of Long-Term Care Claims Denied
							 for Reporting Purposes (line 2 minus line 3 minus line 4)
6
Percentage of Long-Term Care Claims Denied
							 of Those Reported (line 5 divided by line 1)
7
Number of Long-Term Care Claims Denied Due
							 to:
8
Long-Term Care Services Not Covered Under
							 the policy2
9
Provider/Facility Not Qualified Under the
							 Policy3
10
Benefit Eligibility Criteria Not
							 Met4
11
Other
1. The nationwide data may be viewed as a more representative
				  and credible indicator where the data for claims reported and denied for your
				  state are small in number.
2. Example - Home health care claim filed under a nursing
				  home only policy.
3. Example - A facility that does not meet the minimum level
				  of care requirements or the licensing requirements as outlined in the
				  policy.
4. Examples - A benefit trigger not met, certification by a
				  licensed health care practitioner not provided, no plan of
				  care.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix G - Replacement and Lapse Reporting Form

Current through Supplement No. 393, July, 2024
Long-Term Care Insurance Replacement and Lapse
				  Reporting Form
For the State of _____________ For the Reporting Year of
				  _______
Company Name: __________________ Due: June 30
				  annually
Company Address: ________________ Company NAIC Number:
				  ______
Contact Person: ___________________ Telephone Number:
				  (___)______
Instructions
The purpose of this form is to report on a statewide basis
				  information regarding long-term care insurance policy replacements and lapses.
				  Specifically, every insurer shall maintain records for each agent on that
				  agent's amount of long-term care insurance replacement sales as a percentage of
				  the agent's total annual sales and the amount of lapses of long-term care
				  insurance policies sold by the agent as a percentage of the agent's total
				  annual sales. The tables below should be used to report the ten percent (10%)
				  of the insurer's agents with the greatest percentages of replacements and
				  lapses.
Listing of the 10% of Agents With the Greatest
				  Percentage of Replacements
Agent's Name
Number of
							 Policies Sold by This Agent
Number of Policies Replaced by
							 This Agent
Number of Replacements as Percentage of Number
							 Sold by This Agent
Listing of the 10% of Agents With the Greatest
				  Percentage of Lapses
Agent's Name
Number of
							 Policies Sold by This Agent
Number of Policies Replaced by
							 This Agent
Number of Replacements as Percentage of Number
							 Sold by This Agent
Company Totals
Percentage of Replacement Policies Sold to Total Annual
				  Sales _____%
Percentage of Replacement Policies Sold to Policies in Force
				  (as of the end of the preceding calendar year) _____%
Percentage of Lapsed Policies to Total Annual Sales
				  _____%
Percentage of Lapsed Policies to Policies in Force (as of
				  the end of the preceding calendar year) _____%
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-01 - Definitions

Current through Supplement No. 393, July, 2024
As used in this chapter:
1. "Associate member of an employee organization" means any
				  individual who participates in an employee benefit plan (as defined in
				  29 U.S.C.
				  1002(1) ) that is a
				  multiemployer plan (as defined in
				  29 U.S.C.
				  1002(37A) ), other than the
				  following:
a. An individual, or the beneficiary of such individual, who
				  is employed by a participating employer within a bargaining unit covered by at
				  least one of the collective bargaining agreements under or pursuant to which
				  the employee benefit plan is established or maintained; or
b. An individual who is a present or former employee, or a
				  beneficiary of such employee, of the sponsoring employee organization, of an
				  employer who is or was a party to at least one of the collective bargaining
				  agreements under or pursuant to which the employee benefit plan is established
				  or maintained, or of the employee benefit plan or of a related plan.
2. "New entrant" means an eligible employee, or the dependent
				  of an eligible employee, who becomes part of an employer group after the
				  initial period for enrollment in a health benefit plan.
3. "Preexisting condition exclusion" means a limitation or
				  exclusion of benefits relating to a condition based on the fact that the
				  condition was present before the effective date of coverage, whether or not any
				  medical advice, diagnosis, care, or treatment was recommended or received
				  before such date.
4. "Risk characteristic" means the health status, claims
				  experience, duration ofcoverage, health status-related factor, or any similar
				  characteristic related to the health status or experience of a small employer
				  group or of any member of a small employer group.
5. "Risk load" means the percentage above the applicable base
				  premium rate that is charged by a small employer carrier to a small employer to
				  reflect the risk characteristics of the small employer group.
6. "Waiting period" means, with respect to a group health
				  benefit plan and an individual who is a potential participant or beneficiary in
				  the plan, the period that must pass with respect to the individual before the
				  individual is eligible to be covered for benefits under the terms of the plan.
General Authority: NDCC 26.1-01-08
Law Implemented: NDCC
					 26.1-36.3
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-02 - Applicability and scope

Current through Supplement No. 393, July, 2024
1. Except as
				provided in section
				45-06-06.1-13, this chapter
				applies to any health benefit plan, whether provided on a group or individual
				basis, which:
a. Meets one or more of the
				conditions set forth in subdivisions a, b, and c of subsection 1 of North
				Dakota Century Code section 26.1-36.3-02; and
b. Provides coverage to one or more employees
				of a small employer located in this state, without regard to whether the policy
				or certificate was issued in this state.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-03 - Establishment of classes of business

Current through Supplement No. 393, July, 2024
1. A
				small employer carrier that establishes more than one class of business
				pursuant to the provisions of North Dakota Century Code section 26.1-36.3-03
				shall maintain on file for inspection by the commissioner the following
				information with respect to each class of business so established:
a. A description of each criterion employed
				by the carrier or any of its agents for determining membership in the class of
				business;
b. A statement
				describing the justification for establishing the class as a separate class of
				business and documentation that the establishment of the class of business is
				intended to reflect substantial differences in expected claims experience or
				administrative costs related to the reasons set forth in North Dakota Century
				Code section 26.1-36.3-03; and
c.
				A statement disclosing which, if any, health benefit plans are currently
				available for purchase in the class and any significant limitations related to
				the purchase of such plans.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-04 - Transition for assumptions of business from another carrier

Current through Supplement No. 393, July, 2024
1.
a. A
				small employer carrier shall not transfer or assume the entire insurance
				obligation or risk of a health benefit plan covering a small employer in this
				state unless:
(1) The transaction has been
				approved, to the extent required by law, by the insurance supervisory official
				of the state of domicile of the assuming carrier;
(2) The transaction has been approved to the
				extent required by law by the insurance supervisory official of the state of
				domicile of the ceding carrier; and
(3) The transaction otherwise meets the
				requirements of this section.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-06 - Requirement to insure entire groups

Current through Supplement No. 393, July, 2024
1.
a. A small employer carrier that offers
				coverage to a small employer shall offer to provide coverage to each eligible
				employee and to each dependent of an eligible employee. Except as provided in
				subdivision b, the small employer carrier shall provide the same health benefit
				plan to each such employee and dependent.
b. A small employer carrier may offer the
				employees of a small employer the option of choosing among one or more health
				benefit plans, provided that each employee may choose any of the offered plans.
				Except as provided in subsection 3 of North Dakota Century Code section
				26.1-36.3-06, with respect to exclusions for preexisting conditions, the choice
				among benefit plans may not be limited, restricted, or conditioned based upon
				the risk characteristics of the employees or their dependents.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-07 - Consideration of industry

Current through Supplement No. 393, July, 2024
1. Except as
				provided in subsections 2 and 3, a small employer carrier may not consider the
				trade or occupation of the employees of a small employer or the industry or
				type of business in which the small employer is engaged in determining whether
				to issue or continue to provide coverage to the small employer.
2. A small employer carrier may use industry
				as a case characteristic in establishing premium rates, subject to subdivision
				f of subsection 1 of North Dakota Century Code section 26.1-36.3-04.
3. A small employer carrier may consider
				trade, occupation, or industry as part of the eligibility criteria for a class
				of business, subject to paragraph 2 of subdivision b of subsection 1 of North
				Dakota Century Code section 26.1-36.3-06.
General Authority: NDCC 26.1-01-08
Law Implemented: NDCC
					 26.1-36.3
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-08 - Application to reenter state

Current through Supplement No. 393, July, 2024
1. A carrier
				that has been prohibited from writing coverage for small employers in this
				state pursuant to subsection 2 of North Dakota Century Code section
				26.1-36.3-05 may not resume offering health benefit plans to small employers in
				this state until the carrier has made a petition to the commissioner to be
				reinstated as a small employer carrier and the petition has been approved by
				the commissioner. In reviewing a petition, the commissioner may ask for such
				information and assurances as the commissioner finds reasonable and
				appropriate.
2. In the case of a
				small employer carrier doing business in only one established geographic
				service area of the state, if the small employer carrier elects to nonrenew a
				health benefit plan under subdivision f of subsection 1 of North Dakota Century
				Code section 26.1-36.3-05, the small employer carrier shall be prohibited from
				offering health benefit plans to small employers in any part of the service
				area for a period of five years. In addition, the small employer carrier shall
				not offer health benefit plans to small employers in any other geographic area
				of the state without the prior approval of the commissioner. In considering
				whether to grant approval, the commissioner may ask for such information and
				assurances as the commissioner finds reasonable and appropriate.
General Authority: NDCC 26.1-01-08
Law Implemented: NDCC
					 26.1-36.3-05
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-10 - Restrictive riders

Current through Supplement No. 393, July, 2024
1. A restrictive
				rider, endorsement, or other provision that would violate the provisions of
				paragraph 2 of subdivision e of subsection 3 of North Dakota Century Code
				section 26.1-36.3-06 and that was in force on the effective date of this
				chapter may not remain in force beyond the first anniversary date of the health
				benefit plan subject to the restrictive provision that follows the effective
				date of this chapter. A small employer carrier shall provide written notice to
				those small employers whose coverage will be changed pursuant to this
				subsection at least thirty days prior to the required change to the health
				benefit plan.
2. Except as
				permitted in subdivision b of subsection 3 of North Dakota Century Code section
				26.1-36.3-06, a small employer carrier shall not modify or restrict a basic or
				standard health benefit plan in any manner for the purposes of restricting or
				excluding coverage or benefits for specific diseases, medical conditions, or
				services otherwise covered by the plan.
3. Except as permitted in subdivision b of
				subsection 3 of North Dakota Century Code section 26.1-36.3-06, a small
				employer carrier shall not modify or restrict any health benefit plan with
				respect to any eligible employee or dependent of an eligible employee, through
				riders, endorsements, or otherwise, for the purpose of restricting or excluding
				the coverage or benefits provided to such employee or dependent for specific
				diseases, medical conditions, or services otherwise covered by the plan.
General Authority: NDCC 26.1-01-08
Law Implemented: NDCC
					 26.1-36.3-06
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-11 - Rules related to fair marketing

Current through Supplement No. 393, July, 2024
1.
a. A small employer carrier shall actively
				market each of its health benefit plans to small employers in this state. A
				small employer carrier may not suspend the marketing or issuance of a health
				benefit plan unless the carrier has good cause and has received the prior
				approval of the commissioner.
b. In
				marketing the basic and standard health benefit plans to small employers, a
				small employer carrier shall use at least the same sources and methods of
				distribution that it uses to market other health benefit plans to small
				employers. Any producer authorized by a small employer carrier to market health
				benefit plans to small employers in the state shall also be authorized to
				market the basic and standard health benefit plans.
North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-06.1 - Regulation to Implement The Small Employer Health Insurance Availability Act › Section 45-06-06.1-12 - Status of carriers as small employer carriers

Current through Supplement No. 393, July, 2024
1. A carrier shall not offer health benefit
				plans to small employers after January 1, 1994, or continue to provide coverage
				after September 1, 1994, under health benefit plans previously issued to small
				employers in this state, unless the filing provided pursuant to section
				45-06-06-01 indicates the carrier intends to operate as a small employer
				carrier in this state.
2. If the
				filing made pursuant to section 45-06-06-01 indicates that a carrier does not
				intend to operate as a small employer carrier in this state, the carrier shall
				be precluded from operating as a small employer carrier in this state for a
				period of five years from the date of the filing. Upon a written request from
				such a carrier, the commissioner may reduce the period provided for in the
				previous sentence if the commissioner finds that permitting the carrier to
				operate as a small employer carrier would be in the best interests of the small
				employers in the state.
General Authority: NDCC 26.1-01-08, 26.1-36.3-07
Law Implemented: NDCC
					 26.1-36.3-07