reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:28.01 - Applications - Questions about replacement

Current through Register Vol. 51, page 10, July 15, 2024
Application forms shall include 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 the agent, if any, containing the questions may be used. Unless coverage is direct marketed, the agent must ask and record the answers to all questions on the forms.
An insurer may complete or make contractual arrangements for persons other than agents to complete the appropriate application questions. The requirements of chapter 20:06:45 apply to such arrangements. If an insurer uses a contractor or performs the service of completing the application, the contractor or person performing the service must ask the applicant the appropriate application questions and such persons must record the applicant's responses to the questions in the application. While assisting the applicant in completing the application, a contractor is prohibited from attempting to sell or to interest the applicant in purchasing any product. The insurer is responsible for any failure to ask and accurately record the applicant's responses.
Nothing in this section in any way modifies the requirement for a person to hold an insurance agent license if that person sells, solicits, or negotiates insurance.
If the policy is a replacement policy issued to a group defined by SDCL  58-17A-1(6), the required 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 certificateholders have been notified of the replacement.
The questions required by this section are as follows:
(1) Do you have another long-term care insurance policy or certificate in force (including a health care service contract or a health maintenance organization contract)?
(2) Did you have another long-term care insurance policy or certificate in force during the last 12 months?
(a) If so, with which company?
(b) What is the expiration or "paid-to" date of that policy?
(c) If that policy lapsed, when did it lapse?
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:29 - Replacement notices

Current through Register Vol. 51, page 10, July 15, 2024
Upon determining that a sale will involve replacement, an insurer, other than an insurer using direct response solicitation methods or its agent, shall furnish the applicant, before issuance or delivery of the individual long-term care insurance policy, a notice regarding replacement of accident and sickness or long-term care coverage. The applicant shall retain one copy of the notice and the insurer shall retain an additional copy signed by the applicant. The notice must be substantially the same as the notice published in Appendix B at the end of this chapter.
Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long-term care coverage to the applicant upon issuance of the policy. The notice must be substantially the same as the notice published in Appendix C at the end of this chapter.
If replacement is intended, the replacing insurer shall notify, in writing, the existing insurer of the proposed replacement. The existing policy shall be identified by the insurer, name of the insured and policy number, and address, including zip code. The notice shall be made within five working days from the date the application is received by the insurer or the date the policy is issued, whichever is sooner.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:30 - Filing requirements for advertising - Exemption

Current through Register Vol. 51, page 10, July 15, 2024
Each 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 director for review within 30 days of its use. In addition, all advertisements shall be retained by the insurer, health care service plan, or other entity for at least five years from the date the advertisement was first used. The director may exempt from the requirements in this section any advertising form or material if, in the director's opinion, any requirement may not be reasonably applied.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:31 - Standards for marketing - Requirements

Current through Register Vol. 51, page 10, July 15, 2024
Each insurer, health care service plan, or other entity marketing long-term care insurance coverage in this state, directly or through its producers, shall:
(1) Establish marketing procedures and agent training requirements to assure that any comparison of policies by its agents or other producers will be fair and accurate;
(2) Establish marketing procedures and agent training requirements to assure that excessive insurance is not sold or issued;
(3) Display prominently by type, stamp, or other means, on the first page of the outline of coverage and policy the following: "Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations";
(4) Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for long-term care insurance already has accident and sickness or long-term care insurance and the types and amounts of any such insurance ,except 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) Establish auditable procedures for verifying compliance with this section; and
(6) Provide an explanation of contingent benefit upon lapse provided for in subdivision 20:06:21:58(4)(c) and, if applicable, the additional contingent benefit upon lapse provided to policies with fixed or limited premium paying periods in subdivision 20:06:21:58(4)(d).
If the state in which the policy or certificate is to be delivered or issued for delivery has a senior insurance counseling program approved by the director in the state in which the certificate was issued, the insurer shall, at solicitation, provide written notice to the prospective policyholder or certificateholder that such a program is available and the name, address, and telephone number of the program.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:32 - Standards for marketing - Prohibited practices

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the practices prohibited in SDCL chapter 58-33, the following practices are prohibited:
(1) Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing or tending to induce a person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert an insurance policy or to take out a policy of insurance with another insurer;
(2) High pressure tactics. Employing any method of marketing inducing, having the effect of inducing, or tending to induce the purchase of insurance through force, fright, explicit or implied threat, or undue pressure to purchase or recommend the purchase of insurance; and
(3) Cold lead advertising. Making use directly or indirectly of a method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.
(4) Misrepresentation. Misrepresenting a material fact in selling or offering to sell a long-term care insurance policy.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-1,  58-17B-12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:33 - Standards for marketing - Associations

Current through Register Vol. 51, page 10, July 15, 2024
If an association, as defined in SDCL  58-17B-2(4)(c), endorses or sells long-term care insurance, the primary responsibility of the association regarding the obligations set forth in this section is to educate its members concerning long-term care issues in general so that its members can make informed decisions. Associations shall provide objective information regarding long-term care insurance policies or certificates endorsed or sold by it to ensure that members of the association receive a balanced and complete explanation of the features in the policies or certificates that are being endorsed or sold. The obligations are as follows:
(1) The insurer shall file with the division the following material:
(a) The policy and certificate;
(b) A corresponding outline of coverage; and
(c) All advertisements requested by the insurance division.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:34 - Extension of benefits

Current through Register Vol. 51, page 10, July 15, 2024
Termination of long-term care insurance is without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination. Extension of benefits beyond the period the long-term care insurance was in force may be limited to the duration of any benefit period or to payment of the maximum benefits and may be subject to any policy waiting period and all other applicable provisions of the policy.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:35 - Basis for continuation or conversion from group coverage required

Current through Register Vol. 51, page 10, July 15, 2024
Group long-term care insurance issued in this state after October 19, 1996, must provide covered individuals with a basis for continuation or conversion of coverage.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:36 - Basis for continuation of coverage from group defined

Current through Register Vol. 51, page 10, July 15, 2024
For the purposes of §§
									20:06:21:09  to 20:06:21:17, inclusive, §
									20:06:21:35, and this section, a basis for continuation of coverage means a policy provision that maintains coverage under the existing group policy when the coverage would otherwise terminate and that is subject only to the continued timely payment of premiums when due.
Group policies which restrict provision of benefits and services to, or contain incentives to use, certain providers or facilities may provide continuation benefits which are substantially equivalent to the benefits of the existing group policy. The director shall determine the substantial equivalence of benefits. In determining substantial equivalence, the director shall take into consideration the differences between managed care and nonmanaged care plans, including provider system arrangements; service availability; benefit levels; and administrative complexity.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:37 - Reinstatement

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the notice requirement in §
									20:06:21:20, a long-term care insurance policy or certificate must include a provision for reinstatement of coverage in the event of lapse if the insurer is provided proof of cognitive impairment or the loss of functional capacity. This option must be available to the insured if it is requested within five months after termination and must allow for the collection of any past due premium. The standard of proof of cognitive impairment or loss of functional capacity may not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity, if any, contained in the policy or certificate.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:38 - Disclosure of riders and endorsements

Current through Register Vol. 51, page 10, July 15, 2024
Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy, all riders or endorsements added to an individual long-term care insurance policy after the date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy must have a signed acceptance by the individual insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing and signed by the insured unless the increased benefits or coverage are required by law. If a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge must be specified in the policy, rider, or endorsement.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:39 - Disclosure of tax consequences

Current through Register Vol. 51, page 10, July 15, 2024
Life insurance policies which provide an accelerated benefit for long-term care must have a disclosure statement at the time of application for the policy or rider and at the time the accelerated benefit payment request is submitted that receipt of these accelerated benefits may be taxable and that assistance should be sought from a personal tax advisor. The disclosure statement must be prominently displayed on the first page of the policy or rider and any other related documents.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:40 - Applications - Health and medication questions

Current through Register Vol. 51, page 10, July 15, 2024
All applications for long-term care insurance policies or certificates, except those which are guaranteed issue, must contain clear and unambiguous questions designed to ascertain the health condition of the applicant. If an application for long-term care insurance contains a question which asks whether the applicant has had medication prescribed by a physician, it must also ask the applicant to list the medication that has been prescribed. If the medications listed in the application were known, or should have been known, by the insurer 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.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:41 - Applications - Notice about incorrect answers

Current through Register Vol. 51, page 10, July 15, 2024
Except for policies or certificates which are guaranteed issue, the following language must 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.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:42 - Policies - Notice about incorrect answers on applications

Current through Register Vol. 51, page 10, July 15, 2024
Except for policies or certificates which are guaranteed issue, the following language must be set out conspicuously on the long-term care insurance policy or certificate:
Caution: The issuance of this long-term care insurance [policy[ [certificate[ is based upon your response to the questions on your application. A copy of your [application] [enrollment form] [is enclosed] [was retained by you when you applied]. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact the company at this address: [insert address].
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:43 - Elderly applicants - Required information

Current through Register Vol. 51, page 10, July 15, 2024
Before issuance of a long-term care policy or certificate to an applicant age 80 or older, the insurer must obtain one of the following:
(1) A report of a physical examination;
(2) An assessment of functional capacity;
(3) An attending physician's statement; or
(4) Copies of medical records.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:44 - Applications - Delivery

Current through Register Vol. 51, page 10, July 15, 2024
A copy of the completed application or enrollment form, as applicable, must be delivered to the insured no later than at the time of delivery of the policy or certificate unless it was retained by the applicant at the time of application. If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than 30 days after the date of approval.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:45 - Records of rescissions - Maintaining and filing records

Current through Register Vol. 51, page 10, July 15, 2024
Each insurer or other entity selling or issuing long-term care insurance benefits must maintain a record of all policy or certificate rescissions, both state and countrywide, except those which the insured voluntarily effectuated and must annually furnish this information to the director in the format prescribed in Appendix D at the end of this chapter.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:46 - Minimum standards for home health and community care benefits

Current through Register Vol. 51, page 10, July 15, 2024
The following minimum standards for home health and community care benefits must be complied with for long-term care policies, as well as for any policies or certificates that contain stand-alone home health care benefits or home health care benefits issued in conjunction with coverage for long-term care services, other than institutional based long-term care:
(1) If it provides benefits for home health care or community care services, a long-term care insurance policy or certificate may not limit or exclude benefits in any of the following ways:
(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, 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 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 service eligible for coverage;
(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;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:47 - Policy summary for individual life insurance policy containing long-term care benefits

Current through Register Vol. 51, page 10, July 15, 2024
At the time an insurer delivers an individual life insurance policy which provides long-term care benefits within the policy or by rider, the insurer must deliver a policy summary. If the policy is the result of direct response solicitation, the insurer must deliver the policy summary upon the applicant's request, but no later than the time of policy delivery. The summary must also include:
(1) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;
(2) An illustration of the amount of benefits, the length of benefits, and the guaranteed lifetime benefits, if any, for each covered person;
(3) Any exclusions, reductions, and limitations on benefits of long-term care; and
(4) If applicable to the policy type, the summary must also include:
(a) A disclosure of the effects of exercising other rights under the policy;
(b) A disclosure of the premiums attributable to the long-term care component of the policy or certificate;
(c) Current and projected maximum lifetime benefits; and
(d) A disclosure of guarantees related to long-term care costs of insurance charges.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:48 - Monthly report to policyholder

Current through Register Vol. 51, page 10, July 15, 2024
If a long-term care benefit funded through a life insurance vehicle by the acceleration of the death benefit is in benefit payment status, the insurer must provide a monthly report to the policyholder. The report must include:
(1) Any long-term care benefits paid out during the month;
(2) An explanation of any changes in the policy, e.g., death benefits or cash values, caused by long-term care benefits being paid out; and
(3) The amount of long-term care benefits existing or remaining.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:49 - Incontestability period

Current through Register Vol. 51, page 10, July 15, 2024
The following incontestability periods must be complied with for long-term care policies:
(1) For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage;
(2) For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought;
(3) After a policy or certificate has been in force for two years, it is not contestable upon the grounds of misrepresentation alone; the policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health;
(4) A long-term care insurance policy or certificate may be field-issued if the compensation to the field issuer is not based on the number of policies or certificates issued. For purposes of this section, field-issued means a policy or certificate issued by an agent or a third-party administrator pursuant to the underwriting authority granted to the agent or third party administrator by an insurer and using the insurer's underwriting guidelines;
(5) If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer if the policy or certificate is rescinded.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:50 - Assisted living center or facility defined

Current through Register Vol. 51, page 10, July 15, 2024
An assisted living center or facility is any institution, place, building, or agency licensed by the state if such a license is required, which is maintained and operated to provide to five or more individuals personal care and services which meet some basic need beyond provisions of food, shelter, and laundry, in accordance with the following criteria:
(1) Provides 24-hour-a-day care and services sufficient to support needs resulting from an inability to perform activities of daily living or from cognitive impairment;
(2) Has an employee on duty at all times who is awake, trained, and ready to provide care;
(3) Provides three meals a day, including special dietary requirements;
(4) Has formal arrangements for the services of a doctor or nurse to furnish medical care in the event of an emergency; and
(5) Is authorized to administer medication to patients on the order of a doctor.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
License required to operate institution, SDCL  34-12-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:51 - Assisted living centers - Minimum benefit standards

Current through Register Vol. 51, page 10, July 15, 2024
An insurer offering long-term care coverage to any person in this state must include benefits for assisted living centers. If coverage for assisted living centers is provided, the coverage must provide benefits for at least one year in daily amounts not less than half of the daily benefit for nursing facilities. If the daily benefit for assisted living centers is less than that for nursing facilities, the insurer may only deduct the pro-rata difference from the lifetime maximum.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:52 - Reporting requirements for insurers

Current through Register Vol. 51, page 10, July 15, 2024
Each insurer must comply with the following reporting requirements for long-term care policies:
(1) The insurer must maintain records for each agent of that agent's amount of replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales;
(2) The insurer must report to the director annually by June 30 the ten percent of its agents with the greatest percentages of lapses and replacements as measured by subdivision (1) of this section (Appendix J);
(3) The insurer must report to the director annually by June 30 the number of lapsed policies as a percent of its total annual sales and as a percent of its total number of policies in force as of the end of the preceding calendar year (Appendix J);
(4) The insurer must report to the director annually by June 30 the number of replacement policies sold as a percent of its total annual sales and as a percent of its total number of policies in force as of the preceding calendar year (Appendix J); and
(5) Every insurer shall report to the director annually by June 30, for qualified long-term care insurance contracts, the number of claims denied for each class of business, expressed as a percentage of claims denied (Appendix H).
No finding by the director of a violation of insurance laws may be based solely upon reported replacement and lapse rates.
For the purposes of this section, "policy" means only long-term care insurance, "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, "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, and "report" means on a statewide basis.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53 - Appropriateness of recommended purchase or replacement

Current through Register Vol. 51, page 10, July 15, 2024
In recommending the purchase or replacement of a long-term care insurance policy or certificate, an agent must make a reasonable effort to determine the appropriateness of a recommended purchase or replacement. The provisions of §§
									20:06:13:43.01 and 20:06:13:43.02 apply to this chapter.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53.01 - Suitability standards

Current through Register Vol. 51, page 10, July 15, 2024
Every insurer, health care service plan or other entity marketing long-term care insurance, all referred to as the "issuer", shall:
(1) Develop and use suitability standards to determine whether the purchase or replacement of long-term care insurance is appropriate for the needs of the applicant;
(2) Train its agents in the use of its suitability standards; and
(3) Maintain a copy of its suitability standards and make them available for inspection upon request by the director.
To determine if the applicant meets the suitability standards developed by the issuer, as required by this section, the agent and issuer shall develop procedures that consider the following:
(1) The ability to pay for the proposed coverage and other pertinent financial information related to the purchase of the coverage;
(2) The applicant's goals or needs with respect to long-term care and the advantages and disadvantages of insurance to meet these goals or needs; and
(3) The values, benefits, and costs of the applicant's existing insurance, if any, when compared to the values, benefits, and costs of the recommended purchase or replacement.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53.02 - Suitability - Long-term care insurance personal worksheet

Current through Register Vol. 51, page 10, July 15, 2024
The issuer, and when an agent is involved, the agent, shall make reasonable efforts to obtain the information set out in §
									20:06:21:53.01. The efforts must include presentation to the applicant, at or prior to application, the "Long-Term Care Insurance Personal Worksheet." The personal worksheet used by the issuer must contain, at a minimum, the information in the format contained in Appendix E, in not less than 12 point type. The issuer may request the applicant to provide additional information to comply with its suitability standards. A copy of the issuer's personal worksheet shall be filed with the director.
A completed personal worksheet shall be returned to the issuer prior to the issuer's consideration of the applicant for coverage, except the personal worksheet need not be returned for sales of employer group long-term care insurance to employees and their spouses. The sale or dissemination outside the company or agency by the issuer or agent of information obtained through the personal worksheet in Appendix E is prohibited.
The issuer shall use the suitability standards it has developed pursuant to §
									20:06:21:53.01 in determining whether issuing long-term care insurance coverage to an applicant is appropriate. Agents shall use the suitability standards developed by the issuer in marketing long-term care insurance. At the same time as the personal worksheet is provided to the applicant, the disclosure form entitled "Things You Should Know Before You Buy Long-Term Care Insurance" shall be provided. The form must be in the format contained in Appendix F in not less than 12 point type.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53.03 - Suitability - Response letter

Current through Register Vol. 51, page 10, July 15, 2024
If the issuer determines that the applicant does not meet its financial suitability standards, or if the applicant has declined to provide the information, the issuer may reject the application. In the alternative, the issuer shall send the applicant a response letter similar to Appendix G. However, if the applicant has declined to provide financial information, the issuer may use some other method to verify the applicant's intent. Either the applicant's returned letter or a record of the alternative method of verification shall be made part of the applicant's file. The return of the response letter by an applicant indicating a desire to purchase the coverage, does not constitute a defense for any producer for any violation of the insurance laws and rules of this state.
The commission or compensation, for the sale of a long-term care policy or certificate on which the issuer has determined that the applicant does not meet its financial suitability standards, shall be no greater than the renewal compensation.
The issuer shall report annually by June 30 to the director the total number of applicants received from residents of this state, the number of those who declined to provide information on the personal worksheet, the number of applicants who did not meet the suitability standards, and the number of those who chose to confirm after receiving a suitability letter.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53.04 - Suitability - Policies not included

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:21:53.01 to 20:06:21:53.03, inclusive, do not apply to life insurance policies that accelerate benefits for long-term care.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:53.05 - Suitability - Overinsurance

Current through Register Vol. 51, page 10, July 15, 2024
A long-term care insurance policy issued to an individual who already possesses insurance substantially covering the same risk and paying for the same coverage may be deemed to be overinsurance by the director. The issuance of a long-term care policy or certificate to an applicant who has long-term coverage in force and does not intend to replace the current coverage does not per se constitute overinsurance. Overinsurance does not exist unless the benefits of the policies and/or certificates when combined exceed the insured's present or reasonably expected future long-term care needs. In making a determination of whether overinsurance exists, the director shall take into consideration the carrier's overinsurance standards and whether the existing contract does or does not have a cost of living adjustment feature. If the director determines that overinsurance exists, the duplicating insurer must adjust the dates of coverage for any period of time in which overinsurance resulted to remove the duplication and refund or credit premiums toward future coverage accordingly as the duplicating insurer is liable for a full refund less benefits paid. The duplicating policy is void as of the date of issue until such time as the prior coverage terminated. The provisions of this section do not apply to life insurance policies that accelerate benefits for long-term care.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:54 - Requirement to deliver shopper's guide

Current through Register Vol. 51, page 10, July 15, 2024
A long-term care insurance shopper's guide in the format as published by the National Association of Insurance Commissioners or a similar guide developed or approved by the director, must be provided to all prospective applicants of a long-term care insurance policy or certificate.
If the policy is solicited by an agent, the agent must deliver the shopper's guide before presenting an application or enrollment form to the prospective applicant. The shopper's guide must be presented in conjunction with any application or enrollment form if the policy is a direct response solicitation. Life insurance policies or riders containing accelerated long-term care benefits are not required to furnish the shopper's guide, but must furnish the policy summary required by §
									20:06:21:47.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4,  58-17B-10.
"A Shopper's Guide to Long-Term Care Insurance," revised 2005, National Association of Insurance Commissioners. Free copies may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501, (605) 773-3563.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:55 - Standards for benefit triggers

Current through Register Vol. 51, page 10, July 15, 2024
Long-term care policies must comply with the following standards for benefit triggers:
(1) A long-term care policy may require a recommendation by a physician that the services are necessary because of illness, injury, or infirmity, but may not condition benefits on medical necessity. If a long-term care policy provides for medical necessity as an additional mechanism to qualify for benefits, the policy may condition benefits for that additional benefit trigger based on medical necessity;
(2) Long-term care insurance policies must condition the payment of benefits on an assessment of the insured's ability to perform activities of daily living or on cognitive impairment. Activities of daily living included in a policy must include at least the six activities of daily living listed in subdivision 20:06:21:01(1) and as defined in §
									20:06:21:01. Insurers may use activities of daily living to trigger covered benefits in addition to those contained in subdivision 20:06:21:01(1) if they are consistent with or no more restrictive than those contained in subdivision (1) of this section and this subdivision. A determination of impairment may not be more restrictive than requiring either a deficiency in the ability to perform three of the activities of daily living or the presence of cognitive impairment;
(3) An insurer may use additional provisions to determine when benefits are payable under a policy or certificate; however, the provisions may not restrict and may not be in lieu of the requirements contained in subdivisions (1) and (2) of this section;
(4) For purposes of this section, the determination of a deficiency may not be more restrictive than requiring the hands-on assistance of another person to perform the prescribed activities of daily living, or, if the deficiency is due to the presence of a cognitive impairment, needing the supervision or verbal cueing by another person to protect the insured or others;
(5) Assessments of activities of daily living and cognitive impairment must be performed by appropriately credentialed, experienced, trained professionals, such as physicians, registered nurses, or licensed social workers; and
(6) Long-term care insurance policies which condition the payment of benefits on an assessment of the insured's ability to perform activities of daily living or on cognitive impairment must include a clear and understandable description of the method for resolving grievances of the insured, including the process for appealing and resolving benefit determinations.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:56 - Additional standards for benefit triggers for qualified long-term care insurance contracts

Current through Register Vol. 51, page 10, July 15, 2024
A qualified long-term care insurance contract shall pay only for qualified long-term care services received a chronically ill individual provided pursuant to a plan of care prescribed by a licensed health care practitioner. A qualified long-term care insurance contract must condition the payment of benefits on a determination of the insured's inability to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity or to severe cognitive impairment.
Certification regarding activities of daily living and cognitive impairment required pursuant to this section shall be performed by the following licensed or certified professionals: physicians, registered professional nurses, licensed social workers, or other individuals who meet requirements prescribed by the Secretary of the Treasury, if approved by the director. Certifications required pursuant to this section may be performed by any licensed health care professional, or, at the insured's option, a licensed health care professional at the direction of the carrier, as is reasonably necessary with respect to a specific claim, except that when a licensed health care practitioner has certified that an insured is unable to perform activities of daily living for an expected period of at least 90 days due to a loss of functional capacity and the insured is in claim status, the certification may not be rescinded and additional certifications may not be performed until after the expiration of the 90-day period.
Qualified long-term care insurance contracts must include a clear description of the process for appealing and resolving disputes with respect to benefit determinations.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:57 - Nonforfeiture benefits

Current through Register Vol. 51, page 10, July 15, 2024
(1) Except as provided in subdivision 20:06:21:57(2), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. In the event the policyholder or certificateholder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.
(2) When a group long-term care insurance policy is issued, the offer required in subdivision 20:06:21:57(1) shall be made to the group policyholder. However, if the policy is issued as group long-term care insurance as defined in SDCL  58-17B-2(4)(d), other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificateholder.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:58 - Nonforfeiture benefit requirement

Current through Register Vol. 51, page 10, July 15, 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 §
									20:06:21:57:
(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 subdivision (5) of this section; and
(b) The offer must be in writing if the nonforfeiture benefit is not otherwise described in the Outline of Coverage or other materials given to the prospective policyholder;