reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.786 - Standards for marketing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  issuer, directly or through its producers, shall:
(1) Establish marketing procedures to assure
				  that comparison of policies by its 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 policy the following:
"Notice to buyer: This policy may not cover all of your
					 medical expenses."
(4)
				  Inquire and otherwise make every reasonable effort to identify whether a
				  prospective applicant or enrollee for Medicare supplement insurance already has
				  accident and sickness insurance and the types and amounts of this
				  insurance.
(5) Establish auditable
				  procedures for verifying compliance with this subsection.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.787 - Appropriateness of recommended purchase and excessive insurance

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In recommending
				  the purchase or replacement of a Medicare supplement policy or certificate, a
				  producer shall make reasonable efforts to determine the appropriateness of a
				  recommended purchase or replacement.
(b) A sale of Medicare supplement coverage
				  that will provide an individual more than one Medicare supplement policy or
				  certificate is prohibited.
(c) An
				  issuer may not issue a Medicare supplement policy or certificate to an
				  individual enrolled in Medicare Part C unless the effective date of the
				  coverage is after the termination date of the individual's Part C
				  coverage.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.788 - Reporting of multiple policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  On or before March 1 of each year, an issuer shall report the following
				  information for every individual resident of this Commonwealth for which the
				  issuer has in force more than one Medicare supplement policy or certificate.
				  This information must only be submitted for those issuers having insureds with
				  more than one policy:
(1) The policy and
				  certificate number.
(2) The date of
				  issuance.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.789 - Prohibition against preexisting conditions, waiting periods, elimination periods and probationary periods in replacement policies or certificates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a Medicare
				  supplement policy or certificate replaces another Medicare supplement policy or
				  certificate, the replacing issuer shall waive time periods applicable to
				  preexisting conditions, waiting periods, elimination periods and probationary
				  periods in the new Medicare supplement policy or certificate for similar
				  benefits to the extent the time was spent under the original policy.
(b) If a Medicare supplement policy or
				  certificate replaces another Medicare supplement policy or certificate which
				  has been in effect for at least 6 months, the replacing policy may not provide
				  a time period applicable to preexisting conditions, waiting periods,
				  elimination periods and probationary periods for benefits similar to those
				  contained in the original policy or certificate.
This section cited in 31 Pa. Code §
												89.778 (relating to open
						enrollment).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.790 - Guaranteed issue for eligible persons

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Guaranteed issue
.
(1) Eligible persons are those individuals
				  described in subsection (b) who, seek to enroll under the policy during the
				  period specified in subsection (c), and who submit evidence of the date of
				  termination, disenrollment, or Medicare Part D enrollment with the application
				  for a Medicare supplement policy.
(2) With respect to eligible persons, an
				  issuer may not:
(i) Deny or condition the
				  issuance or effectiveness of a Medicare supplement policy described in
				  subsection (e) that is offered and is available for issuance to new enrollees
				  by the issuer.
(ii) Discriminate in
				  the pricing of such a Medicare supplement policy because of health status,
				  claims experience, receipt of health care or medical condition.
(iii) Impose an exclusion of benefits based
				  on a preexisting condition under such a Medicare supplement policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.791 - Prohibition against use of genetic information and requests for genetic testing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This section
				  applies to all Medicare supplement policies with policy years beginning on or
				  after May 21, 2009.
(b) For
				  purposes of this section, the following words and terms have the following
				  meanings, unless the context clearly indicates otherwise:
Issuer
-The issuer of a Medicare
					 supplement policy or certificate as defined in §
											89.772. This term includes a third
					 party administrator, or other person acting for or on behalf of the
					 issuer.
Family member
-A first-degree,
					 second-degree, third-degree or fourth-degree relative of an individual.
Genetic counseling
-Obtaining,
					 interpreting, or assessing genetic information.
Genetic information
-Except for the sex or
					 age of an individual, information regarding:
(i) Genetic tests of an individual or
				  individual's family member.
(ii)
				  The manifestation of a disease or disorder in an individual's family
				  member.
(iii) An individual's
				  request for, or receipt of, genetic services.
(iv) Participation in clinical research
				  involving genetic services by an individual or an individual's family
				  member.
(v) When an individual or
				  family member is a pregnant woman, any reference to information of any fetus
				  carried by the woman.
(vi)
				  Information of any embryo legally held by an individual or family member
				  utilizing reproductive technology.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.801 - Authority and purpose; implementation

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Authority and purpose.
This subchapter is jointly promulgated by the Departments to implement the act
				  under section 7 of the act (40 P. S. §
											3507).
(b)
Implementation.
The
				  Department has primary responsibility for the interpretation and implementation
				  of §§
										89.803-89.805,
				  89.808 and
				  89.809. The Department of Health
				  has primary responsibility for the interpretation and implementation of
				  §§
										89.806 and
				  89.807 (relating to coverage of
				  child immunizations; and immunizing agents, doses and AWPs).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.802 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
ACIP
-The Advisory Committee on
					 Immunization Practices of the Centers for Disease Control and Prevention,
					 United States Department of Health and Human Services.
AWP
-Average wholesale price.
Act
-The Childhood Immunization Insurance
					 Act (40 P. S. §§
											3501-3508).
Child
-An individual covered under a health
					 insurance policy who is either the insured and under 21 years of age, or the
					 insured's spouse and under 21 years of age, or a dependent child pursuant to
					 the definitions of the policy.
Child immunization
-The immunization of a
					 child, in accordance with §
										89.806 (relating to coverage of
					 child immunizations). The immunization will be reimbursed at the rate of the
					 cost of the immunization up to 150% of the AWP of the immunizing agent.
Departments
-The Department of Health and
					 the Insurance Department.
Health insurance policy
-Except for
					 specified disease policies, a group health insurance policy, contract or plan,
					 or an individual policy, contract or plan with dependent coverage for children,
					 which provides medical coverage on an expense-incurred, service or prepaid
					 basis. The term includes the following:
(i) A health insurance policy or contract
				  issued by a nonprofit corporation subject to 40 Pa.C.S. Chapters 61, 63 and 65
				  (relating to hospital plan corporations; professional health services plan
				  corporations; and fraternal benefit societies).
(ii) A health service plan operating under
				  the Health Maintenance Organization Act (40 P. S.
				  §§
											1551-1568).
(iii) A health insurance policy, contract or
				  plan issued by or to an entity not exempt from Pennsylvania law by virtue of
				  the Employee Retirement Income Security Act of 1974 (ERISA) (Pub. L. No.
				  93-406, 88 Stat. 829), including multiple employer welfare arrangements, as
				  defined in section 3(40)(A) of that act (29 U.S.C.A. §
											1002(40)(A)).
Immunization
-The immunizing agent, as well
					 as, its storage and its administration by a person authorized by law to
					 administer an immunizing agent, and a procedure or material associated with the
					 process of immunizing with the exception of a procedure or material employed
					 due to a medical complication such as an adverse reaction to the immunizing
					 agent.
Immunizing agent
-An antigenic substance
					 such as a vaccine or toxoid, or an antibody-containing preparation such as a
					 globulin or antitoxin, when used to actively or passively immunize.
MMWR
-The
Morbidity and Mortality
					 Weekly Report
published by the Centers for Disease Control and
					 Prevention, United States Department of Health and Human
					 Services.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.803 - Provision for coverage in policy

Current through Register Vol. 54, No. 28, July 13, 2024
A health insurance policy which is not exempt from this
					 subchapter under §
										89.809 (relating to exempt
					 policies) and which is delivered, issued for delivery, renewed, extended or
					 modified in this Commonwealth on or after November 22, 1992, shall include
					 coverage for child immunizations.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.804 - Delivery of policy

Current through Register Vol. 54, No. 28, July 13, 2024
If a health insurance policy provides coverage or benefits
					 to a resident of this Commonwealth it shall be deemed to be delivered in this
					 Commonwealth regardless of whether the health care insurer issuing or
					 delivering the policy is located within or outside of this
					 Commonwealth.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.805 - Cost-sharing provisions in policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Applicability.
Child immunization coverage shall be subject to
				  copayment and coinsurance provisions of a health insurance policy to the extent
				  other medical services covered by the policy are subject to those
				  provisions.
(b)
Exemption.
Child immunization coverage shall be exempt from
				  deductible or dollar limit provisions in a health insurance policy. This
				  exemption shall be explicitly provided for in the policy.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.806 - Coverage of child immunizations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Policy coverage.
(1) A health
				  insurance policy which is not exempt from this subchapter under §
											89.809 (relating to exempt
				  policies) shall provide coverage for the cost of the immunization of a child,
				  up to 150% of the AWP of the immunizing agent, if the immunization conforms
				  with ACIP standards in effect on May 21, 1992, governing the issuance of ACIP
				  recommendations for the immunization of children. Those standards are as
				  follows:
(i) The immunization practice is
				  based upon both published and unpublished scientific literature as a means to
				  address the morbidity and mortality of the disease.
(ii) The immunization practice is based upon
				  labeling and packaging inserts for the immunizing agent.
(iii) The immunizing agent is safe and
				  effective.
(iv) The schedule for
				  use of the immunizing agent is administratively feasible.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.807 - Immunizing agents, doses and AWPs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) One hundred fifty percent of the AWP of
				  the immunizing agent that may be used in a child immunization in accordance
				  with §
										89.806 (relating to coverage of
				  child immunizations) is to be calculated by taking 150% of the AWP of the
				  purchase unit for the immunizing agent, using the AWP and purchase unit
				  information contained in the
Blue Book American Druggist First Databank
				  Annual Directory of Pharmaceuticals
as revised in monthly updates
				  prepared by the First Databank Directory of Pharmaceuticals, and then dividing
				  by the number of doses comprising the purchase unit based upon the dose of the
				  immunizing agent used in the child's immunization. Example: If the AWP of the
				  purchase unit (15 dose 7.5 ml vial) of DTP, Lederle, TRI-IMMUNOL is $172.95,
				  150% of the AWP of an 0.5 ml dose of DTP, Lederle, TRI-IMMUNOL = 1.5 (150%) x
				  $172.95 (AWP of the purchase unit) ÷ 15· (number of 0.5 ml doses
				  in 7.5 ml vial) = $17.30.
(b) The
				  Department of Health will place a notice in the
Pennsylvania
				  Bulletin
which contains information on immunizing agents and doses
				  which the Department of Health has extracted from ACIP recommendations issued
				  under the standards in §
										89.806(a). The
				  Department of Health will publish the initial notice contemporaneously with the
				  publication of this subchapter. The Department of Health will update the
				  information in a notice which it will publish in the
Pennsylvania
				  Bulletin
within 30 days after ACIP issues a recommendation pursuant to
				  the standards in §
										89.806(a). The
				  Department of Health will recommend that the information contained in the
				  initial notice and the update to that information contained in a later notice
				  be codified in the
Pennsylvania Code
. The Department of Health
				  will also periodically list AWPs for immunizing agents in a notice which it
				  will publish in the
Pennsylvania Bulletin
. See Appendix
				  H.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation); and 31 Pa. Code Chapter 89, Appendix H (relating to
						immunizing agents and doses).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.808 - Filing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  insurer shall submit to the Department, for its review and approval, a health
				  insurance policy not exempt from this subchapter under §
										89.809 (relating to exempt
				  policies), which is to be delivered, issued for delivery, renewed, extended or
				  modified on or after April 5, 1995. The policy shall contain the necessary
				  provisions to bring it into compliance with the act and this
				  subchapter.
(b) For each health
				  insurance policy issued prior to April 5, 1995, which is not exempt from this
				  subchapter under §
										89.809 (relating to exempt
				  policies), the insurer shall submit to the Insurance Department, by June 5,
				  1995, for its review and approval, a rider or endorsement to bring the policy
				  into compliance with the act and this subchapter.
(c) An insurer shall submit to the
				  Department, for its review and approval, in accordance with the applicable
				  statutory authority, a change in premium rates which is made necessary and
				  appropriate by the insurer's compliance with the act and this
				  subchapter.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter L - CHILDHOOD IMMUNIZATION INSURANCE › Section 89.809 - Exempt policies

Current through Register Vol. 54, No. 28, July 13, 2024
The following types of health insurance policies are not
					 required to provide child immunization coverage:
(1) An indemnity contract in which payment is
				  a specified amount without regard to the actual expense incurred, a contract
				  which provides reimbursement for hospital expenses only, a contract which
				  covers only dental or vision expenses, an accident-only policy, a long-term
				  care insurance policy and a Medicare supplement policy.
(2) A contract which is noncancelable
				  guaranteed renewable which was issued prior to November 22, 1992.
(3) A contract covering a resident of this
				  Commonwealth who is employed outside this Commonwealth by an employer that
				  maintains health insurance for the individual as an employment
				  benefit.
This section cited in 31 Pa. Code §
												89.801 (relating to authority and
						purpose; implementation); 31 Pa. Code §
												89.803 (relating to provision for
						coverage in policy); 31 Pa. Code §
												89.806 (relating to coverage of
						child immunizations); and 31 Pa. Code §
												89.808 (relating to filing
						requirements).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter M - Reserved › Section 89.901-89.921 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
This appendix cited in 31 Pa. Code §
												89.806 (relating to coverage of
						child immunizations).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter M - Reserved › Appendix F

Current through Register Vol. 54, No. 28, July 13, 2024
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Company Name:
______________________________________
Address:
______________________________________
______________________________________
Phone Number:
______________________________________
Due: March 1, annually
The purpose of this form is to report the following
					 information on each resident of this state who has inforce more than one
					 Medicare supplement policy or certificate. The information is to be grouped by
					 individual policyholder.
Policy and Certificate #
Date of Issuance
______________________________________
Signature
______________________________________
Name and Title (please type)
______________________________________
Date
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.101 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The purpose of this chapter is to implement sections
				  1101-1115 of the act (40 P. S. §§
										991.1101-991.1115), 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 care insurance coverages and to facilitate flexibility
				  and innovation in the development of long-term care
				  insurance.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.102 - Applicability and scope

Current through Register Vol. 54, No. 28, July 13, 2024
Except as otherwise specifically provided, this chapter
				  applies to all long-term care insurance policies, including qualified long-term
				  care contracts delivered or issued for delivery in this Commonwealth on or
				  after March 16, 2002, by insurers, fraternal benefit societies, nonprofit
				  hospital plan and professional health services plan corporations, prepaid
				  health plans, health maintenance organizations and all similar organizations.
				  Certain provisions of this chapter apply only to qualified long-term care
				  insurance contracts as noted.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.105 - Policy practices and provisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Renewability.
The terms
				"guaranteed renewable" and "noncancellable" may not be used in an individual
				long-term care insurance policy without further explanatory language in
				accordance with the disclosure requirements of §
									89a.108 (relating to required
				disclosure of rating practices to consumers).
(1) A policy issued to an individual may not
				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 a change in a
				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 a change in a
				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 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 (26 U.S.C.A.
				§
											7702B(b)(1)(C)).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.107 - Required disclosure provisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Renewability.
Individual
				long-term care insurance policies shall contain a renewability provision.
(1) The provision shall be appropriately
				captioned, shall appear on the first page of the policy and shall clearly state
				that the coverage is guaranteed renewable or noncancellable. This provision
				does not apply to policies that do not contain a renewability provision, and
				under which the right to nonrenew is reserved solely to the
				policyholder.
(2) A long-term care
				insurance policy or certificate, other than one in which the insurer does not
				have the right to change the premium, shall include a statement that premium
				rates may change.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.108 - Required disclosure of rating practices to consumers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This section shall apply as follows:
(1) Except as provided in paragraph (2), this
				section applies to a long-term care policy or certificate issued in this
				Commonwealth on or after September 16, 2002.
(2) For certificates issued on or after March
				16, 2002, under a group long-term care insurance policy as defined in section
				1103 of the act (40 P. S. §
											991.1103),
				which policy was in force on March 16, 2002, this section shall apply on the
				policy anniversary following March 17, 2003.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.109 - Initial filing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This
				section applies to a long-term care policy issued in this Commonwealth on or
				after September 16, 2002.
(b) An
				insurer shall provide the information listed in this subsection to the
				Commissioner prior to making a long-term care insurance form available for sale
				subject to sections 3 and 4 of the Accident and Health Filing Reform Act
				(40
				P. S. §§
										3803 and
				3804).
(1) A copy of the disclosure documents
				required in §
										89a.108 (relating to required
				disclosure of rating practices to consumer).
(2) An actuarial certification consisting of
				at least the following:
(i) 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.
(ii)
				A statement that the policy design and coverage provided have been reviewed and
				taken into consideration.
(iii) A
				statement that the underwriting and claims adjudication processes have been
				reviewed and taken into consideration.
(iv) A complete description of the basis for
				contract reserves that are anticipated to be held under the form, to include
				the following:
(A) Sufficient detail or
				sample calculations provided so as to have a complete depiction of the reserve
				amounts to be held.
(B) A statement
				that the assumptions used for reserves contain reasonable margins for adverse
				experience.
(C) A statement that
				the net valuation premium for renewal years does not increase (except for
				attained-age rating where permitted).
(D) 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 this 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.
(v) 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 and a comparison of the premium schedules for similar
				policy forms that are currently available from the insurer with an explanation
				of the differences.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.110 - Prohibition against postclaims underwriting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Applications for long-term care insurance
				policies or certificates except those that are guaranteed issue shall contain
				clear and unambiguous questions designed to ascertain the health condition of
				the applicant.
(b) If an
				application for long-term care insurance contains a question that 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. If the
				medications listed in the 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, the policy or
				certificate may not be rescinded for that condition.
(c) Except for policies or certificates which
				are guaranteed issue:
(1) The following
				language shall be set out conspicuously and in close conjunction with the
				applicant's signature block on an application for a long-term care insurance
				policy or certificate:
Caution: If your answers on this application are incorrect or
				  untrue, [company] has the right to deny benefits or rescind your policy.
(2) The following language, or
				language substantially similar to the following, shall be set out conspicuously
				on the long-term care insurance policy or certificate at the time of delivery:
Caution: The issuance of this long-term care insurance
				  [policy] [certificate] is based upon your responses to the questions on your
				  application. A copy of your [application] [enrollment form] [is enclosed] [was
				  retained by you when you applied]. If your answers are incorrect or untrue, the
				  company has the right to deny benefits or rescind your policy. The best time to
				  clear up questions is now, before a claim arises! If, for any reason, your
				  answers are incorrect, contact the company at this address: [insert
				  address]
(3) Prior to
				issuance of a long-term care policy or certificate to an applicant 80 years of
				age or older, the insurer shall obtain one of the following:
(i) A report of a physical
				examination.
(ii) An assessment of
				functional capacity.
(iii) An
				attending physician's statement.
(iv) Copies of medical records.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.111 - Minimum standards for home health and community care benefits in long-term care insurance policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				A long-term care insurance policy or certificate may not, if it provides
				benefits for home health care or community care services, limit or exclude
				benefits by requiring any of the following:
(1) That the insured or claimant would need
				care in a skilled nursing facility if home health or community care services
				were not provided.
(2) 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.
(3) Limiting eligible services to services
				provided by registered nurses or licensed practical nurses.
(4) That a nurse or therapist provide
				services covered by the policy that can be provided by a home health aide, or
				licensed or certified home care worker acting within the scope of the person
				licensure or certification.
(5)
				Excluding coverage for personal care services provided by a home health
				aide.
(6) That the provision of
				home health or community care services be at a level of certification or
				licensure greater than that required by the eligible service.
(7) That the insured or claimant have an
				acute condition before home health or community care services are
				covered.
(8) Limiting benefits to
				services provided by Medicare-certified agencies or providers.
(9) Excluding coverage for adult day care
				services.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.112 - Requirement to offer inflation protection

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An insurer may not offer a long-term care
				insurance policy unless the insurer also offers to the policyholder in addition
				to 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 shall 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 of at least
				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 may
				not be less than the difference between the existing policy benefit and that
				benefit compounded annually at a rate of at least 5% for the period beginning
				with the purchase of the existing benefit and extending until the year in which
				the offer is made.
(3) Covers a
				specified percentage of actual or reasonable charges and does not include a
				maximum specified indemnity amount or limit.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.113 - Requirements for application forms and replacement coverage

Current through Register Vol. 54, No. 28, July 13, 2024
(a) 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 another accident and sickness or long-term
				care policy or certificate presently in force. A supplementary application or
				form to be signed by the applicant and producer, except when the coverage is
				sold without a producer, containing the questions may be used. With regard to a
				replacement policy issued to a group defined by section 1103 of the act
				(40
				P. S. §
										991.1103), 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 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 or health maintenance organization contract)?
(2) Did you have another long-term care
				insurance policy or certificate in force during the last 12 months?
(i) If so, with which company?
(ii) If that policy lapsed, when did it
				lapse?
(3) Are you
				covered by Medicaid? If you are eligible or covered by Medicaid, you may not
				need to purchase the policy since it may provide duplicate benefits.
(4) Do you intend to replace any of your
				medical or health insurance coverage with this policy [certificate]?
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.114 - Reporting requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Every
				insurer shall maintain records for each producer of that producer's amount of
				replacement sales as a percent of the producer's total annual sales and the
				amount of lapses of long-term care insurance policies sold by the producer as a
				percent of the producer's total annual sales.
(b) Every insurer shall report annually to
				the Department by June 30 the 10% of its producers with the greatest
				percentages of lapses and replacements as measured by subsection (a). (See
				Appendix G (relating to long-term care insurance replacement and lapse
				reporting form).)
(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 producer activities regarding the sale of long-term care
				insurance.
(d) Every insurer shall
				report annually to the Department 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. (See Appendix
				G.).
(e) Every insurer shall report
				annually to the Department 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. (See Appendix
				G.)
(f) Every insurer shall report
				annually to the Department 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. (See Appendix E (relating to claims denial
				reporting form long-term care insurance).)
(g) For purposes of this section:
(1) "Policy" means only long-term care
				insurance.
(2) Subject to paragraph
				(3), "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 terms
				or conditions of the policy have been met.
(3) "Denied" means the insurer refuses to pay
				a claim for reason other than for claims not paid for failure to meet the
				waiting period or because of an applicable preexisting condition.
(4) "Report" means on a Statewide
				basis.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.115 - Licensing

Current through Register Vol. 54, No. 28, July 13, 2024
A producer is not authorized to sell, solicit or negotiate
				  with respect to long-term care insurance except as authorized by sections 601
				  and 621 of the act (40 P. S. §§
										231 and
				  251).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.116 - Reserve standards

Current through Register Vol. 54, No. 28, July 13, 2024
When long-term care benefits are provided, reserves shall be
				  determined in accordance with sections 301.1 and 311.1 of the act
				  (40
				  P. S. §§
										71.1 and
				  93) and Chapter 84a (relating
				  to minimum reserve standards for individual and group health and accident
				  insurance contracts).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.117 - Loss ratio

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This section
				shall apply to all long-term care insurance policies or certificates except
				those covered under §§
									89a.109 and
				89a.118 (relating to initial
				filing requirements; and premium rate schedule increases).
(b) Benefits under long-term care insurance
				policies shall be deemed reasonable in relation to premiums provided the
				expected loss ratio is at least 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 the following:
(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 classification.
(13) Product
				features such as long elimination periods, high deductibles and high maximum
				limits.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.118 - Premium rate schedule increases

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				This section shall apply as follows:
(1)
				Except as provided in paragraph (2), this section applies to a long-term care
				policy or certificate issued in this Commonwealth on or after September 16,
				2002.
(2) For certificates issued
				on or after March 16, 2002, under a group long-term care insurance policy as
				defined in section 1103 of the act (40 P. S. §
											991.1103), which policy was in force on March
				16, 2002, this section shall apply on the policy anniversary following March
				17, 2003.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.119 - Filing requirement

Current through Register Vol. 54, No. 28, July 13, 2024
Prior to an insurer or similar organization offering group
				  long-term care insurance to a resident of this Commonwealth under section 1104
				  of the act (40 P. S. §
										991.1104), 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 Commonwealth.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.120 - Standards for marketing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Every
				insurer, health care service plan or other entity marketing long-term care
				insurance coverage in this Commonwealth, directly or through its producers,
				shall:
(1) Establish marketing procedures and
				producer training requirements to assure that marketing activities, including a
				comparison of policies, by its producers will be fair and accurate and
				excessive insurance is not sold or issued.
(2) 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."
(3) Provide
				copies of the disclosure forms required in §
										89a.108(c)
				(Appendices B and F) (relating to long term care insurance personal worksheet;
				and rate information) to the applicant.
(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 insurance, except that in the case of
				qualified long-term care insurance contracts, an inquiry into whether a
				prospective applicant or enrollee for long-term care insurance has accident and
				sickness insurance is not required.
(5) Every insurer or entity marketing
				long-term care insurance shall establish auditable procedures for verifying
				compliance with this subsection.
(6) Provide written notice to the prospective
				policyholder or certificateholder at solicitation that a senior insurance
				counseling program approved by the Commonwealth 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 §
										89a.105(a)(3)
				(relating to policy practices and provisions).
(8) Provide an explanation of contingent
				benefit upon lapse provided for in §
										89a.123(d)(3)
				(relating to nonforfeiture benefit requirement).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.121 - Suitability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Every insurer,
				nonprofit hospital plan and professional health services plan corporation or
				other entity marketing long-term care insurance (the issuer) shall meet the
				following conditions:
(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 producers
				in the use of its suitability standards.
(3) Maintain a copy of its suitability
				standards and make them available for inspection upon request by the
				Commissioner.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.122 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Register Vol. 54, No. 28, July 13, 2024
If a long-term care insurance policy or certificate replaces
				  another long-term care policy or certificate, the replacing insurer shall waive
				  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.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Section 89a.123 - Nonforfeiture benefit requirement

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Nonforfeiture benefits shall be offered under the following:
(1) 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 (e).
(2) 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.