reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Appendix A - INSURANCE COMMISSIONER STATE OF WEST VIRGINIA

Current through Register Vol. XLI, No. 28, July 12, 2024
GUARANTEED LOSS RATIOS
INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE
				  POLICIES
INSTRUCTIONS:
All questions must be answered; if no
				  answer is applicable, enter the reason for such determination.
I. Policy form number: ________________________________
II. Anticipated lifetime and durational target loss ratios
				  contained in the original actuarial memorandum filed with the policy form when it
				  was originally approved:
_____________________________________________________________________________
III. First calendar year in which the loss ratio guarantee is to
				  be effective:
_____________________________________________________________________________
IV. Source and dates of data used in determining lifetime and
				  durational target loss ratios and credibility data:
_____________________________________________________________________________
V. Name and qualifications of the independent auditor who will
				  perform the annual audit:
				  _____________________________________________________________________________
VI. Attach a sample calculation and illustration of the refund
				  methodology used to comply with the Insurance Commissioner's rule (Title 114, Series
				  31) entitled "Guaranteed Loss Ratios as Applied to Individual Accident and Sickness
				  Insurance Policies."
VII. Guarantees:
(A) The actual West Virginia loss ratios for the experience period
				  in which the new rates take effect, and for each experience period thereafter until
				  new rates are filed, will meet or exceed the anticipated lifetime and durational
				  target loss ratios contained in the original actuarial memorandum noted
				  above.
(B) The actual West Virginia, or, if applicable, national, loss
				  ratio results for the experience period at issue will be independently audited, at
				  this company's expense, as described more fully in section 4 of this rule.
(C) If the actual loss ratio during an experience period is less
				  than the anticipated loss ratio for that period, West Virginia policyholders shall
				  receive proportional refunds based on premium earned, which refunds shall be
				  calculated and paid pursuant to W. Va. Code §
									33-6C-5.
(D) This company does not engage in any discriminatory practices
				  prohibited by W. Va. Code §
									33-11-4
				  [part of the West Virginia Unfair Trade Practices Act], or any such practice which
				  discriminates against any individual on the basis of his or her legal occupation,
				  race, religion or residence.
I hereby certify that the information and guarantees contained in
				  this application are true and correct to the best of my knowledge and belief.
Company Officer's Signature: __________
(TITLE): __________
(DATE): __________
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to implement W. Va. Code §
									33-15A-1
et
				seq
., to promote the public interest, to promote the availability of
				long-term care insurance coverage, to protect applicants for long-term care
				insurance, as defined, from unfair or deceptive sales or enrollment practices, to
				facilitate public understanding and comparison of long-term care insurance
				coverages, and to facilitate flexibility and innovation in the development of
				long-term care insurance. This rule is based on the National Association of
				Insurance Commissioners' ("NAIC") "Long-Term Care Insurance Model Regulation" (Model
				641), as amended in 2009.
Except as otherwise specifically provided, this rule applies to
				  all long-term care insurance policies including qualified long-term care contracts
				  and life insurance policies that accelerate benefits for long-term care delivered or
				  issued for delivery in this state on or after the effective date hereof, by
				  insurers; fraternal benefit societies; nonprofit health, hospital and medical
				  service corporations; prepaid health plans; health maintenance organizations and all
				  similar organizations. Certain provisions of this rule apply only to qualified
				  long-term care insurance contracts as noted.
Additionally, this rule is intended to apply to policies having
				  indemnity benefits that are triggered by activities of daily living and sold as
				  disability income insurance, if:
1.1.a. The
				benefits of the disability income policy are dependent upon or vary in amount based
				on the receipt of long-term care services;
1.1.b. The disability income policy is advertised,
				marketed or offered as insurance for long-term care services; or
1.1.c. Benefits under the policy may commence
				after the policyholder has reached Social Security's normal retirement age unless
				benefits are designed to replace lost income or pay for specific expenses other than
				long-term care services.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
For the purpose of this rule the terms "long-term care insurance,"
				  "qualified long-term care insurance," "group long-term care insurance,"
				  "Commissioner," "applicant," "policy" and "certificate" shall have the meanings set
				  forth in W. Va. Code §
									33-15A-4. In addition, the
				  following definitions apply.
2.1. "Benefit
				trigger", for the purposes of independent review, means a contractual provision in
				the insured's policy of long-term care insurance conditioning the payment of
				benefits on a determination of the insured's ability to perform activities of daily
				living and on cognitive impairment. For purposes of a tax-qualified long-term care
				insurance contract, as defined in section 7702B of the Internal Revenue Code of
				1986, as amended, "benefit trigger" shall include a determination by a licensed
				health care practitioner that an insured is a chronically ill individual.
2.2. "Exceptional increase" means only those
				increases filed by an insurer as exceptional for which the Commissioner determines
				the need for the premium rate increase is justified:
2.2.a. Due to changes in laws or regulations
				applicable to long-term care coverage in this state; or
2.2.b. Due to increased and unexpected utilization
				that affects the majority of insurers of similar products.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-4 - Policy Practices and Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				Renewability -- The terms "guaranteed renewable" and "noncancellable" shall not be
				used in any individual long-term care insurance policy without further explanatory
				language in accordance with the disclosure requirements of section 6 of this rule.
4.1.a. A policy issued to an individual shall not
				contain renewal provisions other than "guaranteed renewable" or
				"noncancellable."
4.1.b. The term
				"guaranteed renewable" may be used only when the insured 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.
4.1.c. The term "noncancellable" may be used only
				when the insured 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
				unilaterally make any change in any provision of the insurance or in the premium
				rate.
4.1.d. The term "level premium"
				may only be used when the insurer does not have the right to change the
				premium.
4.1.e. In addition to the other
				requirements of this subsection, a qualified long-term care insurance contract shall
				be guaranteed renewable, within the meaning of Section 7702B(b)(1)(C) of the
				Internal Revenue Code of 1986, as amended.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-6 - Required Disclosure Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				Renewability. -- Individual long-term care insurance policies shall contain a
				renewability provision.
6.1.a. The provision shall
				be appropriately captioned, shall appear on the first page of the policy, and shall
				clearly state that the coverage is guaranteed renewable or noncancellable. This
				provision shall not apply to policies that do not contain a renewability provision,
				and under which the right to nonrenew is reserved solely to the
				policyholder.
6.1.b. A long-term care
				insurance policy or certificate, other than one where the insurer does not have the
				right to change the premium, shall include a statement that premium rates may
				change.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-7 - Required Disclosure of Rating Practices to Consumers

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. This section shall apply as follows:
7.1.a. Except as provided in subdivision b of this
				subsection, this section applies to any long-term care policy or certificate issued
				in this state on or after September 1, 2009.
7.1.b. For certificates issued on or after the
				effective date of this rule amended in 2009 by the seventy-ninth West Virginia
				Legislature under a group long-term care insurance policy as defined in W. Va Code
				§
										33-15A-4, which policy was
				in force at the time this amended rule became effective, the provisions of this
				section shall apply on the policy anniversary following April 1, 2010.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-8 - Initial Filing Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. This
				section applies to any long-term care policy issued in this state on or after six
				(6) months after the effective date of this rule, amended in 2009.
8.2. An insurer shall provide the information
				listed in this subsection to the Commissioner sixty (60) days prior to making a
				long-term care insurance form available for sale.
8.2.a. A copy of the disclosure documents required
				in section 7 of this rule; and
8.2.b. An
				actuarial certification consisting of at least the following:
8.2.b.1. A statement that the initial premium rate
				schedule is sufficient to cover anticipated costs under moderately adverse
				experience and that the premium rate schedule is reasonably expected to be
				sustainable over the life of the form with no future premium increases
				anticipated;
8.2.b.2. A statement that
				the policy design and coverage provided have been reviewed and taken into
				consideration;
8.2.b.3. A statement that
				the underwriting and claims adjudication processes have been reviewed and taken into
				consideration;
8.2.b.4. A complete
				description of the basis for contract reserves that are anticipated to be held under
				the form, to include:
8.2.b.4.A. Sufficient detail
				or sample calculations provided so as to have a complete depiction of the reserve
				amounts to be held;
8.2.b.4.B. A
				statement that the assumptions used for reserves contain reasonable margins for
				adverse experience;
8.2.b.4.C. A
				statement that the net valuation premium for renewal years does not increase (except
				for attained-age rating where permitted); and
8.2.b.4.D. A statement that the difference between
				the gross premium and the net valuation premium for renewal years is sufficient to
				cover expected renewal expenses; or if such a statement cannot be made, a complete
				description of the situations where this does not occur;
8.2.b.4.D.1. An aggregate distribution of
				anticipated issues may be used as long as the underlying gross premiums maintain a
				reasonably consistent relationship;
8.2.b.4.D.2. If the gross premiums for certain age
				groups appear to be inconsistent with this requirement, the Commissioner may request
				a demonstration under subsection 8.3 of this section based on a standard age
				distribution; and
8.2.b.5.
8.2.b.5.A. A statement that the premium rate
				schedule is not less than the premium rate schedule for existing similar policy
				forms also available from the insurer except for reasonable differences attributable
				to benefits; or
8.2.b.5.B. A comparison
				of the premium schedules for similar policy forms that are currently available from
				the insurer with an explanation of the differences.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-9 - Prohibition Against Post-Claims Underwriting

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. All applications for long-term care insurance
				policies or certificates except those that are guaranteed issue shall contain clear
				and unambiguous questions designed to ascertain the health condition of the
				applicant.
9.2.
9.2.a. If an application for long-term care
				insurance contains a question that asks whether the applicant has had medication
				prescribed by a physician, it must also ask the applicant to list the medication
				that has been prescribed.
9.2.b. If the
				medications listed in the application were known by the insurer, or should have been
				known at the time of application, to be directly related to a medical condition for
				which coverage would otherwise be denied, then the policy or certificate shall not
				be rescinded for that condition.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-10 - Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1. A long-term
				care insurance policy or certificate shall not, if it provides benefits for home
				health care or community care services, limit or exclude benefits:
10.1.a. By requiring that the insured or claimant
				would need care in a skilled nursing facility if home health care services were not
				provided;
10.1.b. By requiring that the
				insured or claimant first or simultaneously receive nursing or therapeutic services,
				or both, in a home, community or institutional setting before home health care
				services are covered;
10.1.c. By
				limiting eligible services to services provided by registered nurses or licensed
				practical nurses;
10.1.d. By requiring
				that a nurse or therapist provide services covered by the policy that can be
				provided by a home health aide, or other licensed or certified home care worker
				acting within the scope of his or her licensure or certification;
10.1.e. By excluding coverage for personal care
				services provided by a home health aide;
10.1.f. By requiring that the provision of home
				health care services be at a level of certification or licensure greater than that
				required by the eligible service;
10.1.g. By requiring that the insured/claimant
				have an acute condition before home health care services are covered;
10.1.h. By limiting benefits to services provided
				by Medicare-certified agencies or providers; or
10.1.i. By excluding coverage for adult day care
				services.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-11 - Requirement to Offer Inflation Protection

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1. No insurer may offer a long-term care
				insurance policy unless the insurer also offers to the policyholder in addition to
				any other inflation protection the option to purchase a policy that provides for
				benefit levels to increase with benefit maximums or reasonable durations which are
				meaningful to account for reasonably anticipated increases in the costs of long-term
				care services covered by the policy. Insurers must offer to each policyholder, at
				the time of purchase, the option to purchase a policy with an inflation protection
				feature no less favorable than one of the following:
11.1.a. Increases benefit levels annually in a
				manner so that the increases are compounded annually at a rate not less than five
				percent (5%);
11.1.b. Guarantees the
				insured individual the right to periodically increase benefit levels without
				providing evidence of insurability or health status so long as the option for the
				previous period has not been declined. The amount of the additional benefit shall be
				no less than the difference between the existing policy benefit and that benefit
				compounded annually at a rate of at least five percent (5%) for the period beginning
				with the purchase of the existing benefit and extending until the year in which the
				offer is made; or
11.1.c. Covers a
				specified percentage of actual or reasonable charges and does not include a maximum
				specified indemnity amount or limit.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-12 - Requirements for Application Forms and Replacement Coverage

Current through Register Vol. XLI, No. 28, July 12, 2024
12.1. Application 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 producer, except where the coverage is sold without a producer,
				containing the questions may be used. With regard to a replacement policy issued to
				a group defined by W. Va. Code §
									33-15A-4(e)(1),
				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 certificateholder has been
				notified of the replacement.
12.1.a. Do you have
				another long-term care insurance policy or certificate in force (including health
				care service contract, health maintenance organization contract)?
12.1.b. Did you have another long-term care
				insurance policy or certificate in force during the last twelve (12) months?
12.1.b.1. If so, with which company?
12.1.b.2. If that policy lapsed, when did it
				lapse?
12.1.c. Are you
				covered by Medicaid?
12.1.d. Do you
				intend to replace any of your medical or health insurance coverage with this policy
				[certificate]?
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-13 - Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1. Every
				insurer shall maintain records for each producer of that producer's amount of
				replacement sales as a percent of the producer's total annual sales and the amount
				of lapses of long-term care insurance policies sold by the producer as a percent of
				the producer's total annual sales.
13.2.
				Every insurer shall report annually by June 30 the ten percent (10%) of its
				producers with the greatest percentages of lapses and replacements as measured by
				subsection 13.1 of this section. (Appendix G)
13.3. 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 producer activities regarding
				the sale of long-term care insurance.
13.4. 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. (Appendix G)
13.5. 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. (Appendix G)
13.6. 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. (Appendix
				E)
13.7. For purposes of this section:
13.7.a. "Policy" means only long-term care
				insurance;
13.7.b. Subject to
				subdivision c 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;
13.7.c. "Denied" means the insurer refuses to pay
				a claim for any reason other than for claims not paid for failure to meet the
				waiting period or because of an applicable preexisting condition; and
13.7.d. "Report" means on a statewide
				basis.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-14 - Licensing

Current through Register Vol. XLI, No. 28, July 12, 2024
A producer is not authorized to sell, solicit or negotiate with
				  respect to long-term care insurance except as authorized by W. Va. Code §
									33-12-1
et
				  seq
.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-15 - Discretionary Powers of Commissioner

Current through Register Vol. XLI, No. 28, July 12, 2024
15.1.
				The Commissioner may upon written request and after an administrative hearing, issue
				an order to modify or suspend a specific provision or provisions of this rule with
				respect to a specific long-term care insurance policy or certificate upon a written
				finding that:
15.1.a. The modification or
				suspension would be in the best interest of the insureds; and
15.1.b. The purposes to be achieved could not be
				effectively or efficiently achieved without the modification or suspension;
				and
15.1.c.
15.1.c.1. The modification or suspension is
				necessary to the development of an innovative and reasonable approach for insuring
				long-term care; or
15.1.c.2. 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
15.1.c.3. 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.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-16 - Reserve Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
16.1. 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 the
				benefits shall be determined in accordance with W. Va. Code §
									33-7-9(3)(a)(A)
				(vii). Claim reserves shall also be established in
				the case when the 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:
16.1.a.
				Definition of insured events;
16.1.b.
				Covered long-term care facilities;
16.1.c. Existence of home convalescence care
				coverage;
16.1.d. Definition of
				facilities;
16.1.e. Existence or absence
				of barriers to eligibility;
16.1.f.
				Premium waiver provision;
16.1.g.
				Renewability;
16.1.h. Ability to raise
				premiums;
16.1.i. Marketing
				method;
16.1.j. Underwriting
				procedures;
16.1.k. Claims adjustment
				procedures;
16.1.l. Waiting
				period;
16.1.m. Maximum
				benefit;
16.1.n. Availability of
				eligible facilities;
16.1.o. Margins in
				claim costs;
16.1.p. Optional nature of
				benefit;
16.1.q. Delay in eligibility
				for benefit;
16.1.r. Inflation
				protection provisions; and
16.1.s.
				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.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-17 - Loss Ratio

Current through Register Vol. XLI, No. 28, July 12, 2024
17.1. This section shall
				apply to all long-term care insurance policies or certificates except those covered
				under sections 8 and 18 of this rule.
17.2. Benefits under long-term care insurance
				policies shall be deemed reasonable in relation to premiums provided the expected
				loss ratio is at least sixty percent (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:
17.2.a. Statistical credibility of
				incurred claims experience and earned premiums;
17.2.b. The period for which rates are computed to
				provide coverage;
17.2.c. Experienced
				and projected trends;
17.2.d.
				Concentration of experience within early policy duration;
17.2.e. Expected claim fluctuation;
17.2.f. Experience refunds, adjustments or
				dividends;
17.2.g. Renewability
				features;
17.2.h. All appropriate
				expense factors;
17.2.i.
				Interest;
17.2.j. Experimental nature of
				the coverage;
17.2.k. Policy
				reserves;
17.2.l. Mix of business by
				risk classification; and
17.2.m. Product
				features such as long elimination periods, high deductibles and high maximum
				limits.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-18 - Premium Rate Schedule Increases

Current through Register Vol. XLI, No. 28, July 12, 2024
18.1. This
				section shall apply as follows:
18.1.a. Except as
				provided in subdivision b of this subsection, this section applies to any long-term
				care policy or certificate issued in this state on or after October 1,
				2009.
18.1.b. For certificates issued on
				or after the effective date of this rule, amended in 2009, under a group long-term
				care insurance policy as defined in W. Va. Code §
										33-15A-4(e)(1),
				which policy was in force at the time this amended rule became effective, the
				provisions of this section shall apply on the policy anniversary following twelve
				(12) months after the effective date of this amended rule.
18.1.c. Except as provided in this section,
				exceptional increases are subject to the same requirements as other premium rate
				schedule increases.
18.1.d. The
				Commissioner may request a review by an independent actuary or a professional
				actuarial body of the basis for a request that an increase be considered an
				exceptional increase.
18.1.e. The
				Commissioner, in determining that the necessary basis for an exceptional increase
				exists, shall also determine any potential offsets to higher claims costs.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-19 - Filing Requirement

Current through Register Vol. XLI, No. 28, July 12, 2024
Prior to an insurer or similar organization offering group
				  long-term care insurance to a resident of this state pursuant to W. Va. Code §
									33-15A-5,
				  it shall file with the Commissioner 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
				  state.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-20 - Filing Requirements for Advertising

Current through Register Vol. XLI, No. 28, July 12, 2024
20.1. Every insurer, health care service plan or
				other entity providing long-term care insurance or benefits in this state shall
				provide a copy of any long-term care insurance advertisement intended for use in
				this state whether through written, radio or television medium to the Commissioner
				for review or approval by the Commissioner to the extent it may be required under
				state law. In addition, all advertisements shall be retained by the insurer, health
				care service plan or other entity for at least three (3) years from the date the
				advertisement was first used.
20.2. The
				Commissioner may exempt from these requirements any advertising form or material
				when in the Commissioner's opinion, this requirement may not be reasonably
				applied.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-21 - Standards for Marketing

Current through Register Vol. XLI, No. 28, July 12, 2024
21.1. Every insurer,
				health care service plan or other entity marketing long-term care insurance coverage
				in this state, directly or through its producers, shall:
21.1.a. Establish marketing procedures and
				producer training requirements to assure that:
21.1.a.1. Any marketing activities, including any
				comparison of policies by its producers or other producers will be fair and
				accurate; and
21.1.a.2. Excessive
				insurance is not sold or issued.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-22 - Appropriateness of Recommended Purchase

Current through Register Vol. XLI, No. 28, July 12, 2024
22.1.
				This section shall not apply to life insurance policies that accelerate benefits for
				long-term care.
22.2. Every insurer,
				health care service plan or other entity marketing long-term care insurance (the
				"issuer") shall:
22.2.a. 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;
22.2.b. Train its producers in the use of its
				suitability standards; and
22.2.c.
				Maintain a copy of its suitability standards and make them available for inspection
				upon request by the Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-23 - Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates

Current through Register Vol. XLI, No. 28, July 12, 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.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-24 - Availability of New Services or Providers

Current through Register Vol. XLI, No. 28, July 12, 2024
24.1. An insurer shall notify policyholders of the
				availability of a new long-term 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
				twelve (12) months of the date of the new policy series is made available for sale
				in this state.
24.2. Notwithstanding
				subsection 24.1 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 had 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 new services or
				providers.
24.3. The insurer shall make
				the new coverage available in one of the following ways:
24.3.a. By adding a rider to the existing policy
				and charging a separate premium for the new rider based on the insured's attained
				age;
24.3.b. 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;
24.3.c. 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
24.3.d. 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 Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-25 - Right to Reduce Coverage and Lower Premiums

Current through Register Vol. XLI, No. 28, July 12, 2024
25.1.
25.1.a.
				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:
25.1.a.1. Reducing the maximum benefit;
				or
25.1.a.2. Reducing the daily, weekly
				or monthly benefit amount.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-26 - Nonforfeiture Benefit Requirement

Current through Register Vol. XLI, No. 28, July 12, 2024
26.1. This
				section does not apply to life insurance policies or riders containing accelerated
				long-term care benefits.
26.2. To comply
				with the requirement to offer a nonforfeiture benefit pursuant to the provisions of
				W. Va. Code §
									33-15A-9:
26.2.a. A policy or certificate offered with
				nonforfeiture benefits shall have coverage elements, eligibility, benefit triggers
				and benefit length that are the same as coverage to be issued without nonforfeiture
				benefits. The nonforfeiture benefit included in the offer shall be the benefit
				described in subsection 26.5 of this section; and
26.2.b. 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.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-27 - Standards for Benefit Triggers

Current through Register Vol. XLI, No. 28, July 12, 2024
27.1. 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 (3) of the activities of daily living or the presence of cognitive
				impairment.
27.2.
27.2.a. Activities of daily living shall include
				at least the following as defined in section 3 and in the policy:
27.2.a.1. Bathing;
27.2.a.2. Continence;
27.2.a.3. Dressing;
27.2.a.4. Eating;
27.2.a.5. Toileting; and
27.2.a.6. Transferring;
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-28 - Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts

Current through Register Vol. XLI, No. 28, July 12, 2024
28.1. For purposes
				of this section the following definitions apply:
28.1.a. "Qualified long-term care services" means
				services that meet the requirements of Section 7702(c)(1) of the Internal Revenue
				Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic,
				curative, treatment, mitigation and rehabilitative services, and maintenance or
				personal care services which are required by a chronically ill individual, and are
				provided pursuant to a plan of care prescribed by a licensed health care
				practitioner.
28.1.b.
28.1.b.1. "Chronically ill individual" has the
				meaning prescribed for this term by section 7702B(c)(2) of the Internal Revenue Code
				of 1986, as amended. Under this provision, a chronically ill individual means any
				individual who has been certified by a licensed health care practitioner as:
28.1.b.1.A. Being unable to perform (without
				substantial assistance from another individual) at least two (2) activities of daily
				living for a period of at least ninety (90) days due to a loss of functional
				capacity; or
28.1.b.1.B. Requiring
				substantial supervision to protect the individual from threats to health and safety
				due to severe cognitive impairment.
28.1.b.2. The term "chronically ill individual"
				shall not include an individual otherwise meeting these requirements unless within
				the preceding twelve-month period a licensed health care practitioner has certified
				that the individual meets these requirements.
28.1.c. "Licensed health care practitioner" means
				a physician, as defined in Section 1861(r)(1) of the Social Security Act, a
				registered professional nurse, licensed social worker or other individual who meets
				requirements prescribed by the Secretary of the Treasury.
28.1.d. "Maintenance or personal care services"
				means any care the primary purpose of which is the provision of needed assistance
				with any of the disabilities as a result of which the individual is a chronically
				ill individual (including the protection from threats to health and safety due to
				severe cognitive impairment).
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-29 - Appealing An Insurer's Determination That The Benefit Trigger Is Not Met

Current through Register Vol. XLI, No. 28, July 12, 2024
29.1. For purposes of
				this section, "authorized representative" is authorized to act as the covered
				person's personal representative within the meaning of
				45
				CFR 164.502(g) promulgated by the
				Secretary of the Department of Health and Human Services under the Administrative
				Simplification provisions of the Health Insurance Portability and Accountability Act
				and means the following:
29.1.a. A person to whom
				a covered person has given express written consent to represent the covered person
				in an external review;
29.1.b. A person
				authorized by law to provide substituted consent for a covered person; or
29.1.c. A family member of the covered person or
				the covered person's treating health care professional only when the covered person
				is unable to provide consent.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-30 - Prompt Payment of Clean Claims

Current through Register Vol. XLI, No. 28, July 12, 2024
30.1. For
				purposes of this section:
30.1.a. "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.
30.1.b. "Clean claim"
				means a claim that has no defect or impropriety, including any lack of required
				substantiating documentation, such as satisfactory evidence of expenses incurred, or
				particular circumstance requiring special treatment that prevents timely payment
				from being made on the claim.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-32 - Requirement to Deliver Shopper's Guide

Current through Register Vol. XLI, No. 28, July 12, 2024
32.1.
				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
				Commissioner, shall be provided to all prospective applicants of a long-term care
				insurance policy or certificate.
32.1.a. In the
				case of t producer solicitations, a producer must deliver the shopper's guide prior
				to the presentation of an application or enrollment form.
32.1.b. In the case of direct response
				solicitation, the shopper's guide must be presented in conjunction with any
				application or enrollment form.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Section 114-32-33 - Penalties

Current through Register Vol. XLI, No. 28, July 12, 2024
In addition to any other penalties provided by the laws of this
				  state, any insurer and any producer found to have violated any requirement of this
				  state relating to the regulation of long-term care insurance or the marketing of
				  such insurance shall be subject to a fine of up to three (3) times the amount of any
				  commissions paid for each policy involved in the violation or up to $10,000,
				  whichever is greater.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Appendix A

Current through Register Vol. XLI, No. 28, July 12, 2024
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF WEST VIRGINIA
FOR THE REPORTING YEAR 20[ ]
Company Name: ____________________
Address: ____________________
Phone Number: ____________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term
				  care insurance policies or certificates. Those rescissions voluntarily effectuated
				  by an insured are not required to be included in this report. Please furnish one
				  form per rescission.
Policy Form #
Policy and Certificate #
Name of Insured
Date of Policy Issuance
Date/s Claim/s Submitted
Date of Rescission
Detailed reason for rescission: _____________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
________________
Signature
________________
Name and Title (please type)
________________
Date