reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3807 - Policy or Certificate Standards for Guaranteed Renewability

Current through Reg. 49, No. 28; July 12, 2024
(a) The term "guaranteed renewability" may be
					 used only when the policyholder has the right to continue the long-term care
					 insurance in force by the timely payment of premiums and when the insurer has
					 no unilateral right to make any change in any provision of the policy or rider
					 while the insurance is in force and cannot decline to renew, except that rates
					 may be revised by the insurer on a class basis. The policyholder retains the
					 right to cancel the long-term care insurance contract with the required notice
					 of cancellation, as outlined in the contract. Upon such cancellation by the
					 policyholder, the insurer must return any unearned premium to the
					 policyholder.
(b) A group long-term
					 care policy may not be described as a guaranteed renewable policy unless the
					 insurer and policyholder have agreed by policy contract provision that the
					 policy cannot be terminated by either the insurer or the policyholder until
					 there are no certificates remaining thereunder. The term "guaranteed
					 renewability" may apply to a group certificate of coverage if and only if the
					 certificate form provides that:
(1) In
					 accordance with the provisions of §
												3.3828
					 of this title (relating to Continuation or Conversion; Discontinuance and
					 Replacement):
(A) a conversion policy will be
					 issued with substantially equivalent benefits upon termination of coverage
					 under the group policy for any reason, including termination of the group
					 policy; or
(B) the certificate may
					 be continued in force under the group policy when the certificate holder is no
					 longer a member of the group, pursuant to a written agreement between the
					 certificate holder and the policyholder regarding such continuation, and that a
					 conversion policy with substantially equivalent benefits must be provided in
					 the event of policy termination; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3810 - Policy or Certificate Standards for Noncancellability

Current through Reg. 49, No. 28; July 12, 2024
(a) The term "noncancellability" may be used
					 only when the policyholder 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 make any change in any provision of the insurance or in
					 the premium rate. The policyholder retains the right to cancel the long-term
					 care insurance contract with the required notice of cancellation, as outlined
					 in the contract. Upon such cancellation by the policyholder, the insurer must
					 return any unearned premium to the policyholder.
(b) A group long-term policy may not be
					 described as a noncancellable policy unless the insurer and policyholder have
					 agreed by policy contract provision that the policy cannot be terminated by
					 either the insurer or the policyholder until there are no certificates
					 remaining thereunder. The term "noncancellable" may apply to a group
					 certificate of coverage if and only if the certificate form provides that:
(1) In accordance with the provisions of
					 §
												3.3828
					 of this title (relating to Continuation or Conversion; Discontinuance and
					 Replacement):
(A) a conversion policy will be
					 issued with substantially equivalent benefits upon termination of coverage
					 under the group policy for any reason, including termination of the group
					 policy; or
(B) the certificate may
					 be continued in force under the group policy when the certificate holder is no
					 longer a member of the group, pursuant to a written agreement between the
					 certificate holder and the policyholder regarding such continuation, and that a
					 conversion policy with substantially equivalent benefits must be provided in
					 the event of policy termination; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3812 - Policy Standards for Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 provider of services, including, but not limited to, assisted living facility,
					 skilled nursing facility, extended care facility, intermediate care facility,
					 convalescent nursing home, maintenance or personal care facility, and home
					 health care agency, shall be defined in relation to the services and facilities
					 required to be available and the licensure or degree status of those providing
					 or supervising the services. Such definitions may not be more restrictive than
					 definitions for the same or similar facilities contained in the Insurance Code
					 or otherwise in legislative enactments for the State of Texas.
(b) The terms, "assisted living facility,"
					 "convalescent nursing home," "extended care facility," "intermediate care
					 facility," or "skilled nursing facility," shall be defined in relation to
					 status, facilities, and available services.
(1) A definition of such home or facility may
					 not be more restrictive than one requiring that it be operated pursuant to
					 state and federal law.
(2) The
					 definition of such home or facility may exclude:
(A) any home, facility, or part thereof used
					 primarily for rest;
(B) a home or
					 facility for the aged or for the care of drug addicts or alcoholics;
					 or
(C) a home or facility primarily
					 used for the care and treatment of mental diseases or disorders, or custodial
					 or educational care.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3815 - Standards for Home Health and Adult Day Care Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) No long-term care insurance policy or
					 certificate which provides benefits for home health care or adult day care
					 services may exclude or limit benefits by requiring any of the following:
(1) that the insured would need care in a
					 nursing facility if home health care services were not provided;
(2) that the insured first or simultaneously
					 receive nursing and/or therapeutic services in a home, community, or
					 institutional setting before home health care services are covered;
(3) that eligible services be provided by a
					 registered nurse or nurses or licensed practical nurse or nurses;
(4) that a nurse or therapist provide
					 services covered by the policy that can be provided by a home health aide, or
					 other licensed or certified home care worker acting within the scope of his or
					 her licensure or certification;
(5)
					 that the provision of home health care services be at a level of certification
					 or licensure greater than that which is required for the eligible service to be
					 performed under the laws of this state;
(6) that the insured have an acute condition
					 before home health care services are offered; or
(7) that benefits be limited to services
					 provided by Medicare certified agencies or providers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3818 - Standards for Eligibility for Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 long-term care insurance policy or certificate shall contain provisions
					 conditioning eligibility for benefits or services upon the occurrence of the
					 following events:
(1) the inability to
					 perform, without assistance, any two activities of daily living, as set forth
					 by the insurer; provided, however, that such activities of daily living shall
					 include at a minimum those which are set forth and defined in §
												3.3804 of
					 this title (relating to Definitions); or
(2) the impairment of cognitive ability. For
					 purposes of this subchapter, the term "impairment of cognitive ability" shall
					 not be defined more restrictively than the deterioration or loss in
					 intellectual capacity requiring substantial supervision for protection of self
					 or others, as established by the clinical diagnosis of any licensed
					 practitioner in this state authorized to make such a diagnosis. Such diagnosis
					 shall include the patient's history and physical, neurological, psychological
					 and/or psychiatric evaluations, and laboratory findings.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3819 - Requirement for Reserve

Current through Reg. 49, No. 28; July 12, 2024
Reserves for long-term care benefits provided pursuant to
						the terms and conditions of policies or certificates which are subject to the
						provisions of this subchapter shall be determined in accordance with Subchapter
						GG of this chapter (relating to Minimum Reserve Standards for Individual and
						Group Accident and Health Insurance).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3820 - Requirement To Offer Inflation Protection

Current through Reg. 49, No. 28; July 12, 2024
(a) No insurer or other entity may offer a
					 long-term care insurance policy or certificate in this state unless such
					 insurer or other entity also offers to the prospective insured, or to the group
					 policyholder, if the group policy will be issued to an employer, labor union,
					 or continuing care retirement center, the option to purchase a policy that
					 provides for benefit levels to increase throughout the interval of coverage to
					 account for reasonably anticipated increases in the costs of long-term care
					 services covered by the policy. Insurers must offer to each applicant, at the
					 time of purchase, the option to purchase a policy that provides the inflation
					 protection set out in paragraphs (1), (2), or (3) of this subsection.
(1) The policy and certificate shall be
					 structured so that benefit levels increase annually, in a manner so that the
					 increases are compounded at a rate not less than 5.0% annually throughout the
					 interval of coverage.
(2) The
					 policy and certificate shall guarantee the policyholder and certificate holder,
					 if applicable, the opportunity to increase benefit levels on the annual policy
					 anniversary date throughout the interval of coverage without providing evidence
					 of insurability or health status, such that the additional benefit amount is
					 not less than 5.0% greater than the original benefit amount, compounded
					 annually. Such increase to benefit levels shall occur automatically unless the
					 policyholders and certificate holders, if applicable, specifically rejected the
					 option to increase in writing within 30 days following the anniversary date of
					 the policy or coverage.
(3) The
					 policy shall cover a specified percentage of actual or reasonable charges
					 throughout the interval of coverage and not include a maximum specified
					 indemnity or per diem amount or limit.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3821 - Limits on Group Long-Term Care Insurance

Current through Reg. 49, No. 28; July 12, 2024
No group long-term care insurance coverage may be offered
						to a resident of this state under a group policy issued in another state to a
						group described in the Insurance Code §
											1251.056 and §
											1131.064, unless the
						Texas Department of Insurance has made a determination that the group long-term
						care insurance requirements adopted by the State of Texas have been met, and
						the certificate for group long-term insurance coverage has been properly filed
						and approved by the department.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3822 - Minimum Standard for Renewability of Long-Term Care Coverage

Current through Reg. 49, No. 28; July 12, 2024
No long-term care insurance policy or certificate issued
						in this state shall contain renewal provisions less favorable to the
						policyholder than guaranteed renewability or noncancellability, as those terms
						are defined in §
											3.3807
						of this title (relating to Policy or Certificate Standards for Guaranteed
						Renewability) and §
											3.3810
						of this title (relating to Policy or Certificate Standards for
						Noncancellability).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3824 - Preexisting Conditions Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) No
					 long-term care insurance policy or certificate issued under provisions of this
					 subchapter may contain a provision which denies a claim for losses incurred
					 more than six months from the effective date of coverage for a preexisting
					 condition, as defined in §
											3.3804 of
					 this title (relating to Definitions).
(b) The definition of preexisting condition
					 does not prohibit an insurer from using an application form designed to elicit
					 the complete health history of an applicant, and on the basis of the answers on
					 that application, from underwriting in accordance with that insurer's
					 established underwriting standards. Unless otherwise provided in the policy or
					 certificate, a preexisting condition, regardless of whether it is disclosed on
					 the application, need not be covered until the waiting period described in
					 subsection (a) of this section expires. No long-term care insurance policy or
					 certificate may exclude or use waivers or riders of any kind to exclude, limit,
					 or reduce coverage or benefits for specifically named or described preexisting
					 diseases or physical conditions beyond the waiting period described in
					 subsection (a) of this section.
(c)
					 Any long-term care insurance policy or certificate which replaces another
					 long-term care policy or certificate shall contain provisions that waive any
					 time periods applicable to preexisting conditions and probationary periods in
					 the new long-term care policy or certificate for similar benefits to the extent
					 that such time periods have been satisfied under the policy being
					 replaced.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3825 - Prior Hospitalization or Institutionalization

Current through Reg. 49, No. 28; July 12, 2024
(a) No long-term care insurance policy or
					 certificate may be delivered or issued for delivery in this state which
					 conditions the eligibility for benefits on prior hospitalization.
(b) No long-term care insurance policy or
					 certificate may be delivered or issued for delivery in this state if such
					 policy conditions eligibility for benefits provided in an institutional care
					 setting on the receipt of a higher level of institutional care.
(c) No long-term care insurance policy or
					 certificate may be delivered or issued for delivery in this state which
					 conditions eligibility for any benefits other than waiver of premium,
					 post-confinement, post-acute care, or recuperative benefits on a prior
					 institutionalization requirement.
(d) Any long-term care insurance policy or
					 certificate containing post-confinement, post-acute care, or recuperative
					 benefits, which are subject to any limitations or conditions for eligibility,
					 including any required number of days of confinement, shall clearly label such
					 limitations or conditions, including any required number of days of
					 confinement, in a separate paragraph of the policy or certificate, entitled
					 "Limitations or Conditions on Eligibility for Benefits."
(1) No long-term care insurance policy or
					 certificate containing a benefit advertised, marketed, or offered as a home
					 care or a home health care benefit may condition receipt of benefits on a prior
					 institutionalization requirement.
(2) No long-term care insurance policy or
					 certificate which conditions eligibility of noninstitutional benefits on the
					 prior receipt of institutional care shall require a prior institutional stay of
					 more than 30 days for which benefits are paid.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3826 - Limitations and Exclusions

Current through Reg. 49, No. 28; July 12, 2024
(a) No policy or
					 certificate may be delivered or issued for delivery in this state as a
					 long-term care insurance policy or certificate if such policy or certificate
					 limits or excludes coverage by type of illness, treatment, medical condition,
					 or accident, except as follows:
(1) a
					 preexisting condition or disease, as defined in §
												3.3804(b)
					 of this subchapter (relating to Definitions); and §
												3.3824
					 of this subchapter (relating to Preexisting Conditions Provisions);
(2) mental or nervous disorders; however,
					 this shall not permit exclusion or limitations of benefits on the basis of the
					 following:
(A) Alzheimer's disease or related
					 disorders, where a clinical diagnosis of Alzheimer's disease by a physician
					 licensed in this state, including history and physical, neurological,
					 psychological and/or psychiatric evaluation, and laboratory studies, has been
					 made to satisfy any requirement or demonstrable proof of organic disease or
					 other proof under the coverage; or
(B) biologically based brain diseases/serious
					 mental illness, including schizophrenia, paranoid and other psychotic
					 disorders, bipolar disorders (mixed, manic, and depressive); major depressive
					 disorders (single episode or recurrent); and schizo-affective disorders
					 (bipolar or depressive);
(3) alcoholism and drug addiction;
(4) illness, treatment, or medical condition
					 arising out of any of the following:
(A) war
					 or act of war, whether declared or undeclared;
(B) participation in a felony, riot, or
					 insurrection;
(C) service in the
					 armed forces or units auxiliary thereto;
(D) suicide, attempted suicide, or
					 intentionally self-inflicted injury; or
(E) aviation activity as a nonfare-paying
					 passenger;
(5) treatment
					 provided in a governmental facility (unless otherwise required by law);
					 benefits provided under Medicare or other governmental program (except
					 Medicaid); any state or federal workers' compensation, employer's liability or
					 occupational disease law, or any motor vehicle no-fault law; services performed
					 by a member of the covered person's immediate family and services for which no
					 charge is normally made in the absence of insurance; or
(6) expenses for services or items available
					 or paid under another long-term care insurance or health insurance
					 policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3827 - Extension of Benefits

Current through Reg. 49, No. 28; July 12, 2024
Termination of long-term care insurance shall be without
						prejudice to any benefits payable for institutionalization, if such
						institutionalization began while the long-term care insurance was in force and
						continues without interruption after termination. Such extension of benefits
						beyond the period the long-term care insurance was in force may be limited to
						the duration of the benefit period, if any, or to payment of the maximum
						benefits, and may be subject to any policy waiting period and all other
						applicable provisions of the policy.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3830 - Requirements for Application Forms and Replacement Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) Individual, direct-response-solicited,
					 and group long-term care insurance application forms shall include questions
					 designed to elicit information as to whether, as of the date of application,
					 the applicant has another long-term care insurance policy or certificate in
					 force or the proposed insurance is intended to replace any other accident and
					 sickness or long-term care insurance policy presently in force. A supplementary
					 application or other form to be signed by the applicant and agent, except where
					 the coverage is sold without an agent, containing such questions may be used.
					 With regard to a replacement policy issued to an employer, labor union, or
					 continuing care retirement community, the following questions may be modified
					 only to the extent necessary to elicit information about health or long-term
					 care insurance policies other than the group policy being replaced; provided,
					 however, that the certificate holder has been notified of the replacement. The
					 following questions shall be included in the application.
(1) Do you have another long-term care
					 insurance policy or certificate in force (including health care service
					 contract, health maintenance organization contract)?
(2) Did you have another long-term care
					 insurance policy or certificate in force during the last 12 months?
(A) If so, with which company?
(B) If that policy lapsed, when did it
					 lapse?
(3) Are you
					 covered by Medicaid?
(4) Do you
					 intend to replace any of your medical or health insurance coverage with this
					 policy (certificate)?
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3831 - Standards and Rates

Current through Reg. 49, No. 28; July 12, 2024
(a) Loss ratio
					 standards. Except as noted in subsections (b) and (c) of this section, this
					 subsection shall apply to all long-term care insurance policies and
					 certificates.
(1) Benefits provided under
					 long-term care insurance policies and certificates shall be deemed reasonable
					 in relation to premiums charged if 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:
(A) statistical credibility of incurred
					 claims experience and earned premiums;
(B) the period for which rates are computed
					 to provide coverage;
(C)
					 experienced and projected trends;
(D) concentration of experience within early
					 policy duration;
(E) expected claim
					 fluctuation;
(F) experience
					 refunds, adjustments, or dividends;
(G) renewability features;
(H) all appropriate expense
					 factors;
(I) interest;
(J) experimental nature of the
					 coverage;
(K) policy
					 reserves;
(L) mix of business by
					 risk classification; and
(M)
					 product features such as long elimination periods, high deductibles, and high
					 maximum limits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3832 - Outline of Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) An outline of
					 coverage must be delivered to an applicant for an individual or group long-term
					 care insurance policy or certificate at the time of initial solicitation
					 through means which prominently direct the attention of the recipient to the
					 document and its purpose. In the case of agent solicitations, the outline of
					 coverage must be delivered prior to the presentation of an application or
					 enrollment form. In the case of direct-response solicitations, the outline of
					 coverage must be delivered in conjunction with any application or enrollment
					 form. The outline of coverage must comply with the following standards and
					 standard format. The contents of the outline of coverage must include the
					 following prescribed text.
(1) The outline of
					 coverage must be a freestanding document, in no smaller than 12-point
					 type.
(2) The outline of coverage
					 must contain no material of an advertising nature.
(3) Text which is capitalized in the standard
					 format outline of coverage must be capitalized. Text which is underscored in
					 the standard format outline of coverage may be emphasized by boldfacing or by
					 other means which provide prominence equivalent to such underscoring.
(4) Use of text and sequence of text of the
					 standard format outline of coverage is mandatory, unless otherwise specifically
					 indicated.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3833 - Group Certificates; Outline of Coverage Required

Current through Reg. 49, No. 28; July 12, 2024
An outline of coverage is required on any group
						certificate issued for group long-term care insurance issued to a group as
						defined in the Insurance Code Chapter 1251 Subchapter B, but subject to the
						exemptions in the Insurance Code §
											1651.002. Such outline
						of coverage shall be in a format identical to that which is required for
						individual long-term care insurance policies in §
											3.3832 of
						this subchapter (relating to Outline of Coverage), and shall be delivered to
						prospective enrollees no later than the time that application for group
						benefits is made.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3834 - Organization of Policy Format for Readability

Current through Reg. 49, No. 28; July 12, 2024
(a) The text of the policy shall be organized
					 so that it follows a logical sequence.
(b) Coverages shall be self-contained and
					 independent.
(c) The use of
					 provisions which refer the reader to another section shall be avoided to the
					 extent possible.
(d) General policy
					 provisions applying to all or several like coverages, such as defined words and
					 terms, shall be located in a common area.
(e) Insurers may utilize a separate
					 definition section for words used throughout the policy. If a separate
					 definition section is used, it shall appear early in the policy
					 format.
(f) Nonessential provisions
					 shall be eliminated.
(g) Captions
					 shall be of type size and style to clearly stand out.
(h) Type size and style must be legible and
					 must comply with the requirements set forth in the Insurance Code §
											1201.054.
(i) Ample blank space shall separate the
					 policy provisions.
(j) Ample blank
					 space shall appear between the columns of printing and the border of the
					 paper.
(k) A table of contents or
					 index may be utilized to enable the policyholder to readily locate particular
					 provisions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3835 - Language Readability

Current through Reg. 49, No. 28; July 12, 2024
(a) Words shall be
					 selected carefully with preference given to short, familiar words.
(b) Words which are generally familiar, or
					 are common speech, shall be used to the extent possible.
(c) Use of technical or abstract words shall
					 be avoided to the extent possible.
(d) While provisions that are more
					 conceptually complex are more difficult to express in simplified language,
					 sentences shall be expressed in the shortest possible manner.
(e) Complex and compound sentences shall be
					 avoided to the extent possible.
(f)
					 The use of prefixes and suffixes shall be avoided to the extent
					 possible.
(g) Each insurer shall
					 submit the readability score for the policy along with the policy when it is
					 submitted for approval. The readability tests set forth in §
											3.3092(c)
					 of this title (relating to Format, Content, and Readability for Outline of
					 Coverage) are recommended as guides for insurers.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3836 - Standards for Policy Certificates Submitted for Approval

Current through Reg. 49, No. 28; July 12, 2024
A certificate issued pursuant to a group long-term care
						insurance policy, which certificate is delivered or issued for delivery in this
						state, shall include:
(1) a
					 description of the principal benefits and coverage provided in the
					 policy;
(2) a statement of the
					 principal exclusions, reductions, and limitations contained in the
					 policy;
(3) a statement that the
					 group master policy determines governing contractual provisions; and
(4) an outline of coverage as provided for in
					 §
											3.3832 of
					 this title (relating to Outline of Coverage) and §
											3.3833
					 of this title (relating to Group Certificates; Outline of Coverage
					 Required).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3837 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Policy or
					 certificate replacements and lapses. The purpose of this subsection is to
					 specify requirements for insurers issuing long-term care insurance benefits in
					 this state to report to the commissioner information on a statewide basis
					 regarding long-term care insurance policy or certificate replacements and
					 lapses.
(1) Agent records.
(A) Each insurer must maintain records, for
					 each agent, of that agent's number and dollar amount of replacement sales as a
					 percentage of the agent's total number and amount of annual sales attributable
					 to long-term care products, as well as the number and dollar amount of lapses
					 of long-term care insurance policies sold by the agent and expressed as a
					 percentage of the agent's total annual sales attributable to long-term care
					 products.
(B) Reported replacement
					 and lapse rates do not alone constitute a violation of insurance laws or
					 necessarily imply wrongdoing. The reports are for the purpose of reviewing more
					 closely agent activities regarding the sale of long-term care
					 insurance.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3838 - Filing Requirements for Advertising

Current through Reg. 49, No. 28; July 12, 2024
A long-term care insurance policy shall not be deemed to
						meet the standards and requirements set forth in this subchapter unless the
						filing company has complied with the requirements of the following
						paragraphs.
(1) Each insurer or other
					 entity providing long-term care insurance or benefits in this state shall
					 provide to the commissioner for review a copy of any long-term care insurance
					 advertisement, as defined in §
											21.102 of this
					 title (relating to Scope of insurance advertising, certain trade practices, and
					 solicitation), other than an institutional advertisement as defined in §
											21.102 of this
					 title that only references long-term care insurance as a line of coverage
					 offered, but which does not otherwise describe long-term care insurance or
					 benefits. The copy of the advertisement shall be submitted to the commissioner
					 no later than 60 days prior to its first use. At the expiration of the 60-day
					 period provided by this paragraph, any advertisement filed with the
					 commissioner shall be deemed acceptable, unless before the end of that 60-day
					 period the commissioner has notified the entity of its nonacceptance.
(2) All advertisements shall comply with all
					 applicable federal and state laws and shall be submitted in accordance with
					 §
											21.120 of this
					 title (relating to Filing for Review). This section does not require prior
					 approval of the advertisement. Nothing in this section relieves any person from
					 otherwise complying with all applicable laws or from any sanction imposed by
					 law.
(3) The insurer or other
					 entity providing long-term care insurance shall retain all advertisements
					 relating to long-term care insurance as provided in §
											21.116
					 of this title (relating to Special Enforcement Procedures for Rules Governing
					 Advertising and Solicitation of Insurance).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3840 - Requirements To Deliver Shopper's Guide

Current through Reg. 49, No. 28; July 12, 2024
A long-term care insurance shopper's guide in the format
						developed by the National Association of Insurance Commissioners shall be
						provided to all prospective applicants of a long-term care insurance policy or
						certificate, as provided in this section.
(1) In the case of agent solicitation, an
					 agent must deliver the shopper's guide prior to the presentation of an
					 application or enrollment form.
(2)
					 In the case of direct response solicitations, the shopper's guide must be
					 presented in conjunction with any application or enrollment form.
(3) At such time the department develops a
					 long-term care insurance shopper's guide, this guide shall be provided to all
					 prospective applicants of a long-term care insurance policy or certificate in
					 lieu of the aforementioned guide.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3842 - Appropriateness of Recommended Purchase

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 In recommending the purchase or replacement of any long-term care insurance
					 policy or certificate, the company and the agent must make reasonable efforts
					 to determine the appropriateness of the recommended purchase or
					 replacement.
(b) Each insurer,
					 health care service plan, or other entity marketing long-term care insurance
					 (issuer) must :
(1) develop and use
					 suitability standards to determine whether the purchase or replacement of
					 long-term care insurance is appropriate for the needs of the
					 applicant;
(2) train its agents in
					 the use of its suitability standards; and
(3) maintain a copy of its suitability
					 standards and make them available for inspection upon request by the
					 commissioner.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3843 - Premium Rate Restrictions

Current through Reg. 49, No. 28; July 12, 2024
Premium rates may not be raised for a covered individual
						unless:
(1) either the covered
					 individual requests and receives a change of benefits; or
(2) the increase is made for all members of
					 the class to which the individual has been assigned by the insurer. The
					 provisions of paragraph (2) of this section do not apply to a noncancellable
					 policy or certificate.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter Y - STANDARDS FOR LONG-TERM CARE INSURANCE, NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE COVERAGE UNDER INDIVIDUAL AND GROUP POLICIES AND ANNUITY CONTRACTS, AND LIFE INSURANCE POLICIES THAT PROVIDE LONG-TERM CARE BENEFITS WITHIN THE POLICY › Division 2 - NON-PARTNERSHIP AND PARTNERSHIP LONG-TERM CARE INSURANCE › Section 3.3844 - Nonforfeiture and Contingent Nonforfeiture Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Required Offering of Nonforfeiture
					 Benefits and Contingent Benefits upon Lapse. No insurer or other entity may
					 offer a long-term care insurance policy or certificate in this state unless
					 such insurer or other entity also offers to the prospective insured, or to the
					 group policyholder, the option to purchase a policy that contains nonforfeiture
					 benefits. On or after July 1, 2002, in the event a policyholder or certificate
					 holder declines the option to purchase a policy that contains nonforfeiture
					 benefits, the insurer shall provide contingent benefits upon lapse as described
					 in subsection (g) of this section. In the event a group policyholder elects to
					 make the nonforfeiture benefit an option to the certificate holder, a
					 certificate shall provide either the nonforfeiture benefit or the contingent
					 benefit upon lapse.
(b)
					 Nonforfeiture Benefit Provisions.
(1) The
					 nonforfeiture provision shall provide for a benefit available in the event of a
					 default in the payment of any premiums. The amount of the benefit may be
					 adjusted subsequent to being initially granted only as necessary to reflect
					 changes in claims, persistency, and interest as reflected in changes in rates
					 for premium paying contracts approved by the commissioner for the same contract
					 form.
(2) The nonforfeiture
					 provision shall be clearly and conspicuously captioned.