reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-110 - Requirements for application forms and replacement coverage

Current through Register Vol. 40, No. 24, July 15, 2024
A. Application or enrollment forms shall
				include the following questions designed to elicit information as to whether,
				as of the date of the application the applicant has another long-term care
				insurance policy or certificate in force or whether a long-term care policy or
				certificate is intended to replace 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 agent, except where the coverage
				is sold without an agent, containing such questions may be used. With regard to
				a replacement policy issued to a group the following questions may be modified
				only to the extent necessary to elicit information about accident and sickness
				or long-term care insurance policies other than the group policy being
				replaced; provided, however, that the certificateholder has been notified of
				the replacement.
1. Do you have another
				long-term care insurance policy or certificate in force (including a health
				services plan 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. 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]
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-120 - Reporting requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Every insurer shall 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.
B. Every insurer shall report annually by
				June 30 the 10% of its agents with the greatest percentages of lapses and
				replacements as measured by subsection A of this section (Form G).
C. Reported replacement and lapse rates do
				not alone constitute a violation of the 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.
D. Every insurer shall report 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 (Form G).
E. Every insurer shall report 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 (Form G).
F. Every insurer shall report 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
				(Form E).
G. For purposes of this
				section:
1. Subject to subdivision 2 of this
				subsection, "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;
2. "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;
3. "Policy" means only long-term care
				insurance; and
4. "Report" means on
				a statewide basis.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-125 - Annual rate reports

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Every insurer shall report to the commission annually premium rates for all
				long-term care insurance policies. The commission shall establish the due date
				and post this report to the Bureau of Insurance's webpage. The rate report
				shall include:
1. For policies issued on or
				after October 1, 2003, an actuarial certification prepared, dated, and signed
				by a qualified actuary that provides at least the following information:
a. A statement of the sufficiency of the
				current premium rate schedule including:
(1)
				For policies currently marketed:
(a) The
				premium rate schedule continues to be sufficient to cover anticipated costs
				under moderately adverse experience, consistent with the margins as defined in
				the original rate filing or any subsequent rate filing, and that the premium
				rate schedule is reasonably expected to be sustainable over the life of the
				form with no future premium increases anticipated; or
(b) If the statement in subdivision 1 a (1)
				(a) of this subsection cannot be made, a statement that margins for moderately
				adverse experience, consistent with the margins as defined in the original rate
				filing or any subsequent rate filing, may no longer be sufficient. In this
				situation, the insurer shall submit to the commission within 60 days of the
				date of the actuarial certification a plan of action, including a timeframe,
				for the reestablishment of adequate margins for moderately adverse experience
				so that the ultimate premium rate schedule would be reasonably expected to be
				sustainable over the future life of the form with no future premium increases
				anticipated. Failure to submit a plan of action to the commission within 60
				days or to comply with the timeframe stated in the plan of action constitutes
				grounds for withdrawal or modification of approval of the form for future
				sales.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-130 - Discretionary powers of commission

Current through Register Vol. 40, No. 24, July 15, 2024
The Commission may upon written request modify or suspend a
				  specific provision or provisions of this chapter with respect to a specific
				  long-term care insurance policy or certificate upon a written finding
				  that:
1. The modification or
				suspension would be in the best interest of the insureds; and
2. The purposes to be achieved could not be
				effectively or efficiently achieved without the modification or suspension; and
a. The modification or suspension is
				necessary to the development of an innovative and reasonable approach for
				insuring long-term care; or
b. The
				policy or certificate is to be issued to residents of a life care or continuing
				care retirement community or some other residential community for the elderly
				and the modification or suspension is reasonably related to the special needs
				or nature of such a community; or
c. The modification or suspension is
				necessary to permit long-term care insurance to be sold as part of, or in
				conjunction with, another insurance product.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-140 - Reserve standards

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				When long-term care benefits are provided through the acceleration of benefits
				under group or individual life policies or riders to such policies, policy
				reserves for such benefits shall be determined in accordance with subdivision 7
				of § 38.2-1369 of the Code of Virginia. Claim reserves must also be
				established in the case when such policy or rider is in claim status. Reserves
				for policies and riders subject to this subsection should be based on the
				multiple decrement model utilizing all relevant decrements except for voluntary
				termination rates. Single decrement approximations are acceptable if the
				calculation produces essentially similar reserves, if the reserve is clearly
				more conservative, or if the reserve is immaterial. The calculations may take
				into account the reduction in life insurance benefits due to the payment of
				long-term care benefits. However, in no event shall the reserves for the
				long-term care benefit and the life insurance benefit be less than the reserves
				for the life insurance benefit assuming no long-term care benefit. In the
				development and calculation of reserves for policies and riders subject to this
				subsection, due regard shall be given to the applicable policy provisions,
				marketing methods, administrative procedures and all other considerations which
				have an impact on projected claim costs, including, but not limited to, the
				following:
1. Definition of insured
				events;
2. Covered long-term care
				facilities;
3. Existence of home
				convalescence care coverage;
4.
				Definition of facilities;
5.
				Existence or absence of barriers to eligibility;
6. Premium waiver provision;
7. Renewability;
8. Ability to raise premiums;
9. Marketing method;
10. Underwriting procedures;
11. Claims adjustment procedures;
12. Waiting period;
13. Maximum benefit;
14. Availability of eligible
				facilities;
15. Margins in claim
				costs;
16. Optional nature of
				benefit;
17. Delay in eligibility
				for benefit;
18. Inflation
				protection provisions; and
19.
				Guaranteed insurability option.
Any applicable valuation morbidity table shall be certified
				  as appropriate as a statutory valuation table by a member of the American
				  Academy of Actuaries.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-150 - Premium rate increases for policies issued before October 1, 2003

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section
				applies to any premium rate increase filed with the commission on or after
				September 1, 2015, for any long-term care insurance policy issued in this
				Commonwealth before October 1, 2003.
B. Benefits under long-term care insurance
				policies shall be deemed reasonable in relation to premiums provided the
				expected loss ratio is the greater of 60% or the lifetime loss ratio used in
				the original pricing applied to the current rate schedule plus:
(i) 80% applied to any premium rate increase
				for individual policy forms or
(ii)
				75% applied to any premium rate increase on group policy forms.
In evaluating the expected loss ratio, due consideration
				  shall be given to all relevant factors, including:
1. Statistical credibility of incurred claims
				experience and earned premiums;
2.
				The period for which rates are computed to provide coverage;
3. Experienced and projected
				trends;
4. Concentration of
				experience within early policy duration;
5. Expected claim fluctuation;
6. Experience refunds, adjustments or
				dividends;
7. Renewability
				features;
8. All appropriate
				expense factors;
9.
				Interest;
10. Experimental nature
				of the coverage;
11. Policy
				reserves;
12. Mix of business by
				risk classification; and
13.
				Product features such as long elimination periods, high deductibles and high
				maximum limits.
Notwithstanding the provisions of
				  14VAC5-130-50 with regard to
				  interest, demonstrations of loss ratios shall be made in compliance with the
				  Rules Governing the Filing of Rates for Individual and Certain Group Accident
				  and Sickness Insurance Policy Forms (14VAC5-130) . All present and accumulated
				  values used to determine rate increases, including the lifetime loss ratio used
				  in the original pricing, shall use the maximum valuation interest rate for
				  contract reserves as specified in § 38.2-1371 of the Code of
				  Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-155 - Filing requirement

Current through Register Vol. 40, No. 24, July 15, 2024
Prior to an insurer or similar organization offering group
				  long-term care insurance to a resident of this Commonwealth pursuant to §
				  38.2-3522.1 of the Code of Virginia, it shall file with the commission evidence
				  that the group policy or certificate thereunder has been approved by a state
				  having statutory or regulatory long-term care insurance requirements
				  substantially similar to those adopted in this Commonwealth.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-160 - Filing requirements for advertising

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every insurer providing long-term care
				insurance or benefits in this Commonwealth shall provide a copy of any
				long-term care insurance advertisement, as defined in
				14VAC5-90-30, intended for use in
				this Commonwealth whether through written, radio or television or other
				electronic medium to the commission. To the extent that it may be required or
				permitted under the laws of this Commonwealth, the commission may review or
				review for approval all such advertisements. In addition, all advertisements
				shall be retained by the insurer for at least three years from the date the
				advertisement was first used.
B.
				The commission may exempt from these requirements any advertising form or
				material when in the commission's opinion, this requirement may not be
				reasonably applied.
Statutory Authority
§§ 12.1-13 and 38.2-5202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-170 - Standards for marketing

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Every insurer, marketing long-term care insurance coverage in this Commonwealth
				directly or through its agents, shall:
1.
				Establish marketing procedures to assure that any comparison of policies by its
				agents will be fair and accurate.
2. Establish marketing procedures to assure
				excessive insurance is not sold or issued.
3. Display prominently by type, stamp or
				other appropriate means on the first page of the 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. Provide
				copies of the disclosure forms (Forms B and F) to the applicant.
5. 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 that in the
				case of qualified long-term care insurance contracts, an inquiry into whether a
				prospective applicant or enrollee for long-term care insurance has accident and
				sickness insurance is not required.
6. Every insurer, marketing long-term care
				insurance shall establish auditable procedures for verifying compliance with
				this subsection.
7. At
				solicitation, provide written notice to the prospective policyholder and
				certificateholder that the Virginia Insurance Counseling and Assistance Program
				is available at: Virginia Department for the Aging, 1610 Forest Avenue, Suite
				100, Richmond, Virginia 23229, Aging Services Hotline 1-800-552-3402.
8. For long-term care health insurance
				policies and certificates, use the terms "noncancellable" or "level premium"
				only when the policy or certificate conforms with
				14VAC5-200-60.
9. Provide an explanation of contingent
				benefit upon lapse provided for in
				14VAC5-200-185 D 3 and, if
				applicable, the additional contingent benefit upon lapse provided to policies
				with fixed or limited premium paying periods in
				14VAC5-200-185 D 4.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-175 - Suitability

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section
				shall not apply to life insurance policies that accelerate benefits for
				long-term care.
B. Every insurer
				marketing long-term care insurance (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 commission.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-181 - Availability of new services or providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. An insurer shall notify policyholders of
				the availability of a new long-term care policy series that provides coverage
				for new long-term care services or providers material in nature and not
				previously available through the insurer to the general public. The notice
				shall be provided within 12 months of the date the new policy series is made
				available for sale in this state.
B. Notwithstanding subsection A of this
				section, notification is not required for any policy issued prior to the
				effective date of this section or to any policyholder or certificateholder who
				is currently eligible for benefits, within an elimination period or on a claim,
				or who previously has been in claim status, or who would not be eligible to
				apply for coverage due to issue age limitations under the new policy. The
				insurer may require that policyholders meet all eligibility requirements,
				including underwriting and payment of the required premium to add such new
				services or providers.
C. The
				insurer shall make the new coverage available in one of the following ways:
1. By adding a rider to the existing policy
				and charging a separate premium for the new rider based on the insured's
				attained age;
2. By exchanging the
				existing policy or certificate for one with an issue age based on the present
				age of the insured and recognizing past insured status by granting premium
				credits toward the premiums for the new policy or certificate. The premium
				credits shall be based on premiums paid or reserves held for the prior policy
				or certificate;
3. By exchanging
				the existing policy or certificate for a new policy or certificate in which
				consideration for past insured status shall be recognized by setting the
				premium for the new policy or certificate at the issue age of the policy or
				certificate being exchanged. The cost for the new policy or certificate may
				recognize the difference in reserves between the new policy or certificate and
				the original policy or certificate; or
4. By an alternative program developed by the
				insurer that meets the intent of this section if the program is filed with and
				approved by the commission.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-183 - Right to reduce coverage and lower premiums

Current through Register Vol. 40, No. 24, July 15, 2024
A.
1. Every
				long-term care insurance policy and certificate shall include a provision that
				allows the policyholder or certificateholder to reduce coverage and lower the
				policy or certificate premium in at least one of the following ways:
a. Reducing the maximum benefit; or
b. Reducing the daily, weekly or monthly
				benefit amount.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-185 - Nonforfeiture benefit requirement

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section does not apply to life
				insurance policies or riders containing accelerated long-term care
				benefits.
B. To comply with the
				requirement to offer a nonforfeiture benefit pursuant to the provisions of
				§ 38.2-5210 of the Code of Virginia:
1.
				A policy or certificate offered with nonforfeiture benefits shall have coverage
				elements, eligibility, benefit triggers and benefit length that are the same as
				coverage to be issued without nonforfeiture benefits. The nonforfeiture benefit
				included in the offer shall be the benefit described in subsection E of this
				section; and
2. The offer shall be
				in writing if the nonforfeiture benefit is not otherwise described in the
				Outline of Coverage or other materials given to the prospective policyholder.
When a group long-term care insurance policy is issued, the
				  offer required in § 38.2-5210 of the Code of Virginia shall be made to the
				  group policyholder. However, if the policy is issued as group long-term care
				  insurance as defined in § 38.2-3522.1 of the Code of Virginia other than
				  to a continuing care retirement community or other similar entity, the offer
				  shall be made to each proposed certificateholder.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-187 - Standards for benefit triggers

Current through Register Vol. 40, No. 24, July 15, 2024
A. A long-term care insurance policy shall
				condition the payment of benefits on a determination of the insured's ability
				to perform activities of daily living and on cognitive impairment. Eligibility
				for the payment of benefits shall not be more restrictive than requiring either
				a deficiency in the ability to perform not more than three of the activities of
				daily living or the presence of cognitive impairment.
B.
1.
				Activities of daily living shall include at least the following as defined in
				14VAC5-200-50 and in the policy:
a. Bathing;
b. Continence;
c. Dressing;
d. Eating;
e. Toileting; and
f. Transferring.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-190 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Register Vol. 40, No. 24, July 15, 2024
If a long-term care insurance policy or certificate replaces
				  another long-term care policy or certificate, the replacing insurer shall waive
				  any time periods applicable to preexisting conditions and probationary periods
				  in the new long-term care policy for similar benefits to the extent that
				  similar exclusions have been satisfied under the original
				  policy.
Statutory Authority
§§ 38.2-223 and 38.2-5200 through 38.2-5208 of
					 the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-195 - Rate increase hearings

Current through Register Vol. 40, No. 24, July 15, 2024
The commission may, at its sole discretion and as a condition
				  of approval, conduct a public hearing or order an insurer to present
				  information concerning its premium rate increase submission before the
				  commission if it determines that a hearing or presentation is in the public
				  interest. One consideration for a hearing may be the percentage or level of
				  premium rate increase requested.
Statutory Authority: §§ 12.1-13, 38.2-223, and
					 38.2-5202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-201 - Requirement to deliver shopper's guide

Current through Register Vol. 40, No. 24, July 15, 2024
A. A long-term care insurance shopper's guide
				in the format developed by the National Association of Insurance Commissioners,
				or a guide developed or approved by the commission, shall be provided to all
				prospective applicants of a long-term care insurance policy or certificate.
1. In the case of agent solicitations, 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.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-205 - State Long-Term Care Insurance Partnership Program

Current through Register Vol. 40, No. 24, July 15, 2024
A. In accordance with § 6021 of the
				Deficit Reduction Act of 2005 (
				Pub.L.
				109-171 ) and § 32.1-325 of the Code of
				Virginia, in addition to the applicable provisions of this chapter, the
				provisions of this section shall apply to any qualified state long-term care
				insurance partnership policy.
B.
				"Qualified state long-term care insurance partnership policy" or "partnership
				policy" means an insurance policy that meets all the requirements specified in
				12VAC30-40-290 and meets the
				following requirements:
1. The policy covers
				an insured who was a resident of the Commonwealth of Virginia (a Partnership
				State) when coverage first became effective under the policy.
2. The policy is a qualified long-term care
				insurance policy as defined in § 7702B(b) of the Internal Revenue Code of
				1986 and was issued no earlier than September 1, 2007.
3. The policy meets all the applicable
				requirements of this chapter and the requirements of the National Association
				of Insurance Commissioners long-term care insurance model act and model
				regulation as those requirements are set forth in § 1917(b)(5)(A) of the
				Social Security Act ( 42 USC § 1396p(b)(5)(A) ).
4. The policy provides the following
				inflation protections:
a. If the policy is
				sold to an individual who has not attained age 61 as of the date of purchase,
				the policy shall provide a compound annual inflation protection feature at
				least equivalent to the provisions of
				14VAC5-200-100;
b. If the policy is sold to an individual who
				has attained age 61 but has not attained age 76 as of the date of purchase, the
				policy shall provide an inflation protection feature at least equivalent to the
				provisions of
				14VAC5-200-100;
c. If the policy is sold to an individual who
				has attained age 76 as of the date of purchase, the policy may provide
				inflation protection, but shall at least comply with the provisions of
				14VAC5-200-100.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-210 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter or the application thereof
				  to any person or circumstances is for any reason held to be invalid, the
				  remainder of this chapter and the application of such provision to other
				  persons or circumstances shall not be affected thereby.
Statutory Authority
§§ 38.2-223 and 38.2-5200 through 38.2-5208 of
					 the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Form - FORMS (14VAC5-200)

Current through Register Vol. 40, No. 24, July 15, 2024
Rescission
				  Reporting Form, Form A (eff. 2/2002)
Long-Term
				  Care Insurance Personal Worksheet, Form B (rev. 4/2015)
Things
				  You Should Know Before You Buy Long-Term Care Insurance, Form C (rev.
				  9/2007)
Long-Term
				  Care Insurance Suitability Letter, Form D (rev. 2/2002)
Claims
				  Denial Reporting Form, Form E (rev. 4/2015)
Potential
				  Rate Increase Disclosure Form, Form F (rev. 12/2015)
Replacement
				  and Lapse Reporting Form, Form G (eff. 9/2007)
Partnership
				  Program Notice, Form 200-A (eff. 9/2007)
Partnership
				  Disclosure Notice, Form 200-B (eff. 9/2007)
Long-Term
				  Care Partnership Certification Form, Form 200-C (rev.
				  4/2015)
Statutory Authority: §§ 12.1-13, 38.2-223, and
					 38.2-5202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part I - Applicability and Definitions › Section 14VAC5-211-10 - Applicability and scope

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  This chapter sets forth rules to carry out the provisions of Chapter 43 (§
				  38.2-4300 et seq.) of Title 38.2 of the Code of Virginia, and applies to all
				  health maintenance organizations and to all health maintenance organization
				  contracts and evidences of coverage delivered or issued for delivery by a
				  health maintenance organization established or operating in this
				  Commonwealth.
B. In the event of
				  conflict between the provisions of this chapter and the provisions of any other
				  rules issued by the commission, the provisions of this chapter shall be
				  controlling as to health maintenance organizations.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part II - Financial Condition Requirements › Section 14VAC5-211-30 - Covered and uncovered expenses

Current through Register Vol. 40, No. 24, July 15, 2024
A. Health maintenance organizations licensed
				  in this Commonwealth shall report to the commission on a form prescribed by the
				  commission all uncovered expenses for the three-month periods ending on
				  December 31, March 31, June 30, and September 30 on or before March 1, May 15,
				  August 15, and November 15, respectively, of each year. This statement of
				  covered and uncovered expenses shall be filed with each annual and quarterly
				  financial statement pursuant to § 38.2-4307.1C of the Code of
				  Virginia.
B. Each expense of a
				  health maintenance organization that is owed or paid to a health care provider
				  under contract with a health maintenance organization shall be considered a
				  covered health care expense by that health maintenance organization if (i) the
				  contract between the health maintenance organization and the health care
				  provider contains the hold harmless clause required by § 38.2-5805C 9 of
				  the Code of Virginia and (ii) the expense falls within the scope of the hold
				  harmless clause.
C. If there is an
				  intermediary organization between the health maintenance organization and the
				  health care providers, the hold harmless clause shall be amended to include
				  nonpayment by either the health maintenance organization or the intermediary
				  organization. The hold harmless clause shall be included in any contract
				  between the intermediary organization and health care providers and in any
				  contract between the health maintenance organization and the intermediary
				  organization before health care expenses owed or paid to the intermediary
				  organization shall be considered covered expenses.
D. A health maintenance organization may
				  request permission from the commission to treat other types of expenses as
				  covered expenses. The request shall be in writing and state the health
				  maintenance organization's justification for the requested treatment. In no
				  case shall a health maintenance organization treat an expense, other than those
				  set forth in subsections B and C of this section, as a covered expense without
				  the prior approval of the commission.
E. Each expense that is not a covered expense
				  under this section shall be considered an uncovered expense.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part II - Financial Condition Requirements › Section 14VAC5-211-40 - Surplus notes

Current through Register Vol. 40, No. 24, July 15, 2024
For the purpose of recognizing surplus notes, no debt
					 shall be considered subordinated unless (i) it qualifies for recognition as a
					 surplus note and can be reported as surplus (equity) in accordance with §
					 38.2-4300 of the Code of Virginia, and (ii) the subordination clause set forth
					 below is executed by the health maintenance organization and the lender.
Subordination Clause
The rights of lender to the principal sum and/or accrued
					 interest thereon are and shall remain subject to and subordinate to all other
					 liabilities of health maintenance organization, and, upon the dissolution or
					 liquidation of health maintenance organization, no payment upon this instrument
					 shall be made until all other liabilities of the plan shall have been paid. It
					 is further agreed to by and between the parties hereto that written approval
					 from the State Corporation Commission must be obtained prior to any repayment
					 of principal or payment of interest.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part II - Financial Condition Requirements › Section 14VAC5-211-50 - Financial projections

Current through Register Vol. 40, No. 24, July 15, 2024
The commission may require a health maintenance
					 organization licensed in Virginia to submit to it periodic updates of the
					 projection of operating results required by § 38.2-4301B 11 of the Code of
					 Virginia. Each update shall also include a complete explanation of any
					 significant variance between actual operating results and the operating results
					 that were forecasted under the projection last submitted to the commission and
					 documentation of all critical assumptions. Critical assumptions include, but
					 are not limited to, enrollment levels, premium rates, provider reimbursements,
					 utilization rates, risk-sharing arrangements with providers, general and
					 administrative expenses, excess and other insurance expenses and recoveries,
					 coordination of benefits, costs of long-term financing, and inflation. The
					 commission may revise or request a revision of any financial projection that it
					 deems to be unreasonable relative to the health maintenance organization's
					 historic performance.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-60 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-70 - Continuation of coverage

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
				  enrollee whose eligibility for coverage terminates under the group contract
				  shall have the opportunity to continue coverage under the existing group
				  contract for a period of at least 12 months immediately following the date of
				  termination of the enrollee's eligibility for coverage under the group
				  contract. Continuation coverage shall not be applicable if the group contract
				  holder is required by federal law to provide for continuation of coverage under
				  its group health plan pursuant to the Consolidated Omnibus Budget
				  Reconciliation Act (COBRA) ( P.L. 99-272 ). Coverage shall be provided without
				  additional evidence of insurability subject to the following requirements:
1. The
				  application and payment for the continued coverage is made to the group
				  contract holder within 31 days after issuance of the written notice required in
				  subsection C of this section, but in no event beyond the 60-day period
				  following the date of the termination of the person's eligibility;
2.
				  Each premium for the continued coverage is timely paid to the group contract
				  holder on a monthly basis during the 12-month period; and
3. The
				  premium for continuing the group coverage shall be at the health care plan's
				  current rate applicable to similarly situated individuals under the group
				  contract plus any applicable administrative fee not to exceed 2.0% of the
				  current rate.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-80 - Coordination of benefits

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  health care plan may include in its group or individual contract a provision
				  that the value of any benefit or service provided by the health maintenance
				  organization may be coordinated with other health insurance or health care
				  benefits or services that are provided by other individual or group policies,
				  contracts, or health care plans, including coverage provided under governmental
				  programs, so that no more than 100% of the eligible incurred expenses is
				  paid.
B. A health care plan shall
				  not be relieved of its duty to provide a covered health care service to an
				  enrollee because the enrollee is entitled to coverage under other policies,
				  contracts, or health care plans. In the event that benefits are provided by a
				  health care plan and another policy, contract, or health care plan, the
				  determination of the order of benefits shall in no way restrict or impede the
				  rendering of services required to be provided by the health care plan. The
				  health maintenance organization shall be required to provide or arrange for the
				  service first and then, at its option, seek coordination of benefits with any
				  other health insurance or health care benefits or services that are provided by
				  other policies, contracts, or plans. Until a coordination of benefits
				  determination is made, the enrollee shall not be held liable for the cost of
				  covered services provided.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-90 - Cost sharing

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Except for preventive services required by § 38.2-3442 of the Code of
				  Virginia, a health maintenance organization may require a copayment of
				  enrollees as a condition for the receipt of a specific health care service. A
				  copayment shall be shown in the evidence of coverage as either a specified
				  dollar amount or as coinsurance.
B.
				  If the health maintenance organization has an established out-of-pocket maximum
				  for cost sharing, it shall keep accurate records of each enrollee's cost
				  sharing and notify the enrollee when his out-of-pocket maximum is reached. The
				  notification shall be given no later than 30 days after the health maintenance
				  organization has processed sufficient claims to determine that the
				  out-of-pocket maximum is reached. The health maintenance organization shall not
				  charge additional cost sharing for the remainder of the contract or calendar
				  year, as appropriate. The health maintenance organization shall also promptly
				  refund to the enrollee all cost sharing payments charged after the
				  out-of-pocket maximum is reached. Any maximum out-of-pocket amount shall be
				  shown in the evidence of coverage as a specified dollar amount, and the
				  evidence of coverage shall clearly state the health maintenance organization's
				  procedure for meeting the requirements of this subsection.
C. A grandfathered plan that excludes a
				  deductible from the out-of-pocket maximum may continue to do so as long as the
				  plan remains grandfathered.
D. The
				  provisions of this subsection shall not apply to any Family Access to Medical
				  Insurance Security (FAMIS) Plan (i) authorized by the United States Centers for
				  Medicare and Medicaid Services pursuant to Title XXI of the Social Security Act
				  ( 42 USC § 1397aa et seq.) and the state plan established pursuant to
				  Chapter 13 (§ 32.1-351 et seq.) of Title 32.1 of the Code of Virginia and
				  (ii) underwritten by a health maintenance organization.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-100 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-110 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-120 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-130 - Extension of benefits for total disability

Current through Register Vol. 40, No. 24, July 15, 2024
A. A group contract issued by a health
				  maintenance organization in the large group market shall contain a reasonable
				  extension of benefits upon discontinuance of the group contract with respect to
				  enrollees who become totally disabled while enrolled under the contract and who
				  continue to be totally disabled at the date of discontinuance of the
				  contract.
B. Upon payment of
				  premium, coverage shall remain in full force and effect for a reasonable period
				  of time not less than 180 days, or until the enrollee is no longer totally
				  disabled, or a succeeding carrier elects to provide replacement coverage to
				  that enrollee without limitation as to the disabling condition.
C. The
				  provisions of this section shall not apply to contracts entered into by any
				  health maintenance organization that has contracted with the Virginia
				  Department of Medical Assistance Services to provide health care services to
				  recipients of medical assistance services pursuant to Title XIX of the Social
				  Security Act, as amended, or to individuals covered by the Family Access to
				  Medical Insurance Security Insurance (FAMIS) plan developed pursuant to Title
				  XXI of the Social Security Act, as amended.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-140 - Freedom of choice

Current through Register Vol. 40, No. 24, July 15, 2024
A. At
				  the time of enrollment an enrollee shall have the right to select a primary
				  care health care professional from among the health maintenance organization's
				  affiliated primary care health care professionals, subject to availability and
				  in accordance with § 38.2-3443 of the Code of Virginia.
B. An enrollee who is dissatisfied with his
				  primary care health care professional shall have the right to select another
				  primary care health care professional from among the health maintenance
				  organization's affiliated primary care health care professionals, subject to
				  availability. The health maintenance organization may impose a reasonable
				  waiting period for this transfer.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part III - Contract Requirements › Section 14VAC5-211-150 - Complaint and appeals procedure

Current through Register Vol. 40, No. 24, July 15, 2024
A. A health maintenance organization shall
				  establish and maintain a complaint system to provide reasonable procedures for
				  the prompt and effective resolution of written complaints in accordance with
				  Chapter 5 (§ 32.1-137.1 et seq.) of Title 32.1 and Chapter 58 (§
				  38.2-5800 et seq.) of Title 38.2 of the Code of Virginia. In addition, a health
				  maintenance organization shall establish and maintain an internal appeals
				  procedure in accordance with Chapter 5 (§ 32.1-137.1 et seq.) of Title
				  32.1 and Chapter 35.1 (§ 38.2-3556 et seq.) of Title 38.2 of the Code of
				  Virginia and applicable regulations. A record of all written complaints shall
				  be maintained for the period specified in § 38.2-511 of the Code of
				  Virginia. A record of all requests for internal appeal shall be maintained in
				  accordance with the provisions of § 32.1-137.16 of the Code of
				  Virginia.
B. Pending the resolution
				  of a written complaint filed by a subscriber or enrollee, coverage may not be
				  terminated for the subscriber or enrollee for any reason that is the subject of
				  the written complaint, except where coverage is being terminated or rescinded
				  in accordance with
				  14VAC5-211-230.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.