South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix L - Partnership Certification Form

Current through Register Vol. 51, page 10, July 15, 2024
LONG-TERM CARE PARTNERSHIP
CERTIFICATION FORM
Note: This Form must be completed and submitted with each long-term care policy or certificate form for which the insurer is seeking partnership qualification. A separate form must be completed for each policy form and a specimen copy of the form, including all riders and endorsements, must be attached. A long-term care policy or certificate form may not be issued in South Dakota as a partnership policy or certificate unless and until this form has been submitted to and approved by the Division of Insurance.
Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C. 1396 p(b)(5)(iii)) and in accordance with applicable South Dakota requirements, the insurer hereby submits information relating to policy or certificate form _____________ (form number) to substantiate that the form includes all required consumer protection requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42 U.S.C. 1396 p(b)(5)(A)) and that it includes certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (adopted as of October 2000) (referred to herein as the "2000 Model Regulation" and "2000 Model Act," respectively).
Part I:
Name of Insurer ___________________________________________
Company NAIC # ___________________________________________
Address ___________________________________________
___________________________________________
___________________________________________
Telephone ___________________________________________
Company Contact
Name ___________________________________________
Title ___________________________________________
Telephone ___________________________________________
E-Mail ___________________________________________
Part II:
2000 NAIC MODEL REGULATION AND 2000 NAIC MODEL ACT
Note to Insurer: Identify the page and/or provision within the policy or certificate form that addresses each requirement, or, if inapplicable, use the space identified to explain.
Policy/Certificate form ________________ meets the following requirements of the 2000 NAIC Model Long-Term Care Regulation and/or 2000 NAIC Model Long-Term Care Act, as indicated below:
NAIC Model Regulation Requirement
Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable
Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the 2000 Model Act relating to such section 6A.
Section 6B (relating to prohibitions on limitations and exclusions) other than paragraph (7) thereof.
Section 6C (relating to extension of benefits).
Section 6D (relating to continuation or conversion of coverage).
Section 6E (relating to discontinuance and replacement of policies).
Section 7 (relating to unintentional lapse).
Section 8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.
Section 9 (relating to required disclosure of rating practices to consumer).
Section 11 (relating to prohibitions against post-claims underwriting).
Section 12 (relating to minimum standards).
Section 14 (relating to application forms and replacement coverage).
Section 15 (relating to reporting requirements).
Section 22 (relating to filing requirements for marketing).
Section 23 (relating to standards for marketing, including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C).
Section 24 (relating to suitability).
Section 25 (relating to prohibition against preexisting conditions and probationary periods in replacement policies or certificates).
Section 26 (relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986 (26 U.S.C. 7702 B(g)(4)).
Section 29 (relating to standard format outline of coverage).
Section 30 (relating to requirement to deliver shopper's guide).
NAIC Model Act Requirement
Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable
Section 6C (relating to preexisting conditions).
Section 6D (relating to prior hospitalization).
Section 8 (relating to contingent nonforfeiture benefits).
Section 6F (relating to right to return).
Section 6G (relating to outline of coverage).
Section 6H (relating to requirements for certificates under group plans).
Section 6J (relating to policy summary).
Section 6K (relating to monthly reports on accelerated death benefits).
Section 7 (relating to incontestability period).
Part III. INFLATION PROTECTON
Identify the policy provision or provide form number of endorsement or amendment form (and date of approval) for inflation protection coverage in compliance with ARSD 20:06:21:76:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Part IV.
CERTIFICATION
I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct, and complete and the policy [certificate] satisfies the requirements necessary for a qualified state long-term care insurance partnership policy in the State of South Dakota.
________________________ _____________________________________
Date Name and title of officer of the Insurer
________________________ _____________________________________
Date Signature of officer of the Insurer