Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.31 - Standard Format Outline of Coverage

Current through June 14, 2024
A. This section
				  of the Part implements, interprets and makes specific, the provisions of R.I.
				  Gen. Laws §
										27-34.2-6(H) in
				  prescribing a standard format and the content of an outline of
				  coverage.
B. The outline of
				  coverage shall be a free-standing document, using no smaller than ten-point
				  type.
C. The outline of coverage
				  shall contain no material of an advertising nature.
D. Text which is capitalized or underscored
				  in the standard format outline of coverage may be emphasized by other means
				  that provide prominence equivalent to such capitalization or
				  underscoring.
E. Use of the text
				  and sequence of text of the standard format outline of coverage is mandatory,
				  unless otherwise specifically indicated.
F. Format for outline of coverage:
[COMPANY NAME]
[ADDRESS - CITY & STATE]
[TELEPHONE NUMBER]
LONG-TERM CARE INSURANCE OUTLINE OF COVERAGE
[Policy Number or Group Master Policy and Certificate
					 Number]
[Except for policies or certificates which are guaranteed
					 issue, the following caution statement, or language substantially similar, must
					 appear as follows in the outline of coverage.]
Caution: The issuance of this long-term care insurance
					 [policy] [certificate] is based upon your responses to the questions on your
					 application. A copy of your [application] [enrollment form] [is enclosed] [was
					 retained by you when you applied]. If your answers are incorrect or untrue, the
					 company has the right to deny benefits or rescind your policy. The best time to
					 clear up 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]
1. The policy is [an
				  individual policy of insurance] ([a group policy] which was issued in the
				  [indicate jurisdiction in which group policy was issued]).
2. PURPOSE OF OUTLINE OF COVERAGE. This
				  outline of coverage provides a very brief description of the important features
				  of the policy. You should compare this outline of coverage to outlines of
				  coverage for other policies available to you. This is not an insurance
				  contract, but only a summary of coverage. Only the individual or group policy
				  contains governing contractual provisions. This means that the policy or group
				  policy sets forth in detail the rights and obligations of both you and the
				  insurance company. Therefore, if you purchase this coverage, or any other
				  coverage, it is important that you READ YOUR POLICY (OR CERTIFICATE)
				  CAREFULLY!
3. FEDERAL TAX
				  CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to be a federally
					 tax-qualified long-term care insurance contract under Section  7702B(b)   of the
					 Internal Revenue Code of 1986, as amended.
OR
Federal Tax Implications of this [POLICY] [CERTIFICATE].
					 This [POLICY] [CERTIFICATE] is not intended to be a federally tax-qualified
					 long-term care insurance contract under Section  7702B(b)   of the Internal
					 Revenue Code of 1986 as amended. Benefits received under the [POLICY]
					 [CERTIFICATE] may be taxable as income.
4. TERMS UNDER WHICH THE POLICY OR
				  CERTIFICATE MAY BE CONTINUED IN FORCE OR DISCONTINUED.
(a) [For long-term care health insurance
				  policies or certificates describe one of the following permissible policy
				  renewability provisions:]
(1) [Policies and
				  certificates that are guaranteed renewable shall contain the following
				  statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS GUARANTEED RENEWABLE.
				  This means you have the right, subject to the terms of your policy,
				  [certificate] to continue this policy as long as you pay your premiums on time.
				  [Company Name] cannot change any of the terms of your policy on its own, except
				  that, in the future. IT MAY INCREASE THE PREMIUM YOU PAY.
(2) [Policies and certificates that are
				  noncancellable shall contain the following statement:] RENEWABILITY: THIS
				  POLICY [CERTIFICATE] IS NONCANCELLABLE. This means that you have the right,
				  subject to the terms of your policy, to continue this policy as long as you pay
				  your premiums on time. [Company Name] cannot change any of the terms of your
				  policy on its own and cannot change the premium you currently pay. However, if
				  your policy contains an inflation protection feature where you choose to
				  increase your benefits, [Company Name] may increase your premium at that time
				  for those additional benefits.
(b) [For group coverage, specifically
				  describe continuation/conversion provisions applicable to the certificate and
				  group policy;]
(c) [Describe waiver
				  of premium provisions or state that there are not such provisions;]
5. TERMS UNDER WHICH THE POLICY OR
				  CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief description of the right
				  to return -- "free look" provision of the policy.]
(b) [Include a statement that the policy
				  either does or does not contain provisions providing for a refund or partial
				  refund of premium upon the death of an insured or surrender of the policy or
				  certificate. If the policy contains such provisions, include a description of
				  them.]
6. TERMS UNDER
				  WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
(a) [Provide a brief description of the right
				  to return- "free look" provision of the policy.]
(b) [Include a statement that the policy
				  either does or does not contain provisions providing for a refund or partial
				  refund of premium upon the death of an insured or surrender of the policy or
				  certificate. If the policy contains such provisions, include a description of
				  them.]
7. THIS IS NOT
				  MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the
				  Medicare Supplement Buyer's Guide available from the insurance company.
(a) [For producers] Neither [insert company
				  name] nor its producers represent Medicare, the federal government or any state
				  government.
(b) [For direct
				  response] [insert company name] is not representing Medicare, the federal
				  government or any state government.
8. LONG-TERM CARE COVERAGE. Policies of this
				  category are designed to provide coverage for one or more necessary or
				  medically necessary diagnostic, preventive, therapeutic, rehabilitative,
				  maintenance, or personal care services, provided in a setting other than an
				  acute care unit of a hospital, such as in a nursing home, in the community or
				  in the home.
This policy provides coverage in the form of a fixed dollar
					 indemnity benefit for covered long-term care expenses, subject to policy
					 [limitations] [waiting periods] and [coinsurance] requirements. [Modify this
					 paragraph if the policy is not an indemnity policy.]
9. BENEFITS PROVIDED BY THIS POLICY.
(a) [Covered services, related deductible(s),
				  waiting periods, elimination periods and benefit maximums.]
(b) [Institutional benefits, by skill
				  level.]
(c) [Non-institutional
				  benefits, by skill level.]
(d)
				  Eligibility for Payment of Benefits
[Activities of daily living and cognitive impairment shall
					 be used to measure an insured's need for long-term care and must be defined and
					 described as part of the outline of coverage.]
[Any additional benefit triggers must also be explained. If
					 these triggers differ for different benefits, explanation of the triggers
					 should accompany each benefit description. If an attending physician or other
					 specified person must certify a certain level of functional dependency in order
					 to be eligible for benefits, this too must be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a)
				  Preexisting conditions;
(b)
				  Non-eligible facilities/provider;
(c) Non-eligible levels of care (e.g.,
				  unlicensed providers, care or treatment provided by a family member,
				  etc.);
(d)
				  Exclusions/exceptions;
(e)
				  Limitations.]
[This section should provide a brief specific description
					 of any policy provisions which limit, exclude, restrict, reduce, delay, or in
					 any other manner operate to qualify payment of the benefits described in (9)
					 above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
					 YOUR LONG-TERM CARE NEEDS.
11. RELATIONSHIP OF COST OF CARE AND
				  BENEFITS. Because the costs of long-term care services will likely increase
				  over time, you should consider whether and how the benefits of this plan may be
				  adjusted. [As applicable, indicate the following:
(a) That the benefit level will not increase
				  over time;
(b) Any automatic
				  benefit adjustment provisions;
(c)
				  Whether the insured will be guaranteed the option to buy additional benefits
				  and the basis upon which benefits will be increased over time if not by a
				  specified amount or percentage;
(d)
				  If there is such a guarantee, include whether additional underwriting or health
				  screening will be required, the frequency and amounts of the upgrade options,
				  and any significant restrictions or limitations;
(e) And finally, describe whether there will
				  be any additional premium charge imposed, and how that is to be
				  calculated.]
12.
				  ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS.
[State that the policy provides coverage for insureds
					 clinically diagnosed as having Alzheimer's disease, other dementias or organic
					 brain disorder. Specifically describe each benefit screen or other policy
					 provision which provides preconditions to the availability of policy benefits
					 for such an insured.]
13.
				  PREMIUM
[(a) State the total annual premium
				  for the policy;
(b) If the premium
				  varies with an applicant's choice among benefit options, indicate the portion
				  of annual premium which corresponds to each benefit option.]
14. ADDITIONAL FEATURES
[(a) Indicate if medical underwriting is
				  used;
(b) Describe other important
				  features.]
15. CONTACT
				  THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF YOU HAVE GENERAL
				  QUESTIONS REGARDING LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF
				  YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE POLICY OR
				  CERTIFICATE.