reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-135 - Standards for benefit triggers

Current through Register Vol. 24-14, July 15, 2024
(1) A long-term care insurance policy must
			 condition the payment of benefits on a determination of the insured's ability
			 to perform activities of daily living or on cognitive impairment of the
			 insured. Eligibility for the payment of benefits must 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.
(2)
(a) Activities of daily living must include
			 at least the following, as defined in WAC
			 284-83-015, and must be defined
			 in the policy:
(i) Bathing;
(ii) Continence;
(iii) Dressing;
(iv) Eating;
(v) Toileting; and
(vi) Transferring;
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-140 - Qualified long-term care insurance policies - Additional standards for benefit triggers

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of this section the following definitions apply:
(a) "Qualified long-term care services" means services that meet the requirements of Section  7702B(c)(1) of the Internal Revenue Code of 1986, as amended, including: 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.
(b)
(i) "Chronically ill individual" has the meaning of 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:
(A) Being unable to perform (without substantial assistance from another individual) at least two activities of daily living for a period of at least ninety days due to a loss of functional capacity; or
(B) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.
(ii) The term "chronically ill individual" does not include an individual otherwise meeting these requirements unless within the preceding twelve-month period a licensed health care practitioner certified that the individual meets these requirements.
(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 federal Secretary of the Treasury.
(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).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-150 - Requirement to deliver shopper's guide

Current through Register Vol. 24-14, July 15, 2024
(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, must be
			 provided to all prospective applicants of a long-term care insurance policy or
			 certificate.
(a) In the case of solicitations
			 by an insurance producer, the insurance producer must deliver the shopper's
			 guide prior to the presentation of an application or enrollment form.
(b) In the case of direct response
			 solicitations, the shopper's guide must be presented in conjunction with any
			 application or enrollment form.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-155 - Prohibited practices

Current through Register Vol. 24-14, July 15, 2024
The following practices are prohibited:
(1) No insurance producer or other
			 representative of the issuer may complete the medical history portion of any
			 form or application, including an electronic application, for the purchase of a
			 long-term care policy.
(2) No
			 issuer or insurance producer or other representative of the issuer may
			 knowingly sell a long-term care policy to any person who is receiving
			 medicaid.
(3) No issuer or
			 insurance producer or other representative of the issuer may use or engage in
			 any unfair or deceptive act or practice in the advertising, sale or marketing
			 of long-term care policies.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-155, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-165 - Form for reporting rescission of long-term care policies

Current through Register Vol. 24-14, July 15, 2024
The following form must be used by issuers to annually report
				rescission of long-term care policies.
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE
				STATE
OF 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
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-165, filed 11/24/08,
				  effective 12/25/08.
Reviser's note:
The brackets and enclosed
				  material in the text of the above section occurred in the copy filed by the
				  agency.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-180 - Response letter

Current through Register Vol. 24-14, July 15, 2024
The following form of response letter must be used in this
				state.
Long-Term Care Insurance Suitability Letter
Dear [Applicant]:
Your recent application for long-term care insurance included a
				"personal worksheet," which asked questions about your finances and your
				reasons for buying long-term care insurance. For your protection, state law
				requires us to consider this information when we review your application, to
				avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not
				meet your financial needs. We suggest that you review the information provided
				along with your application, including the booklet "Shopper's Guide to
				Long-Term Care Insurance" and the page titled "Things You Should Know Before
				Buying Long-Term Care Insurance." Your state insurance department also has
				information about long-term care insurance and may be able to refer you to a
				counselor free of charge who can help you decide whether to buy this
				policy.]
[You chose not to provide any financial information for us to
				review.]
Note: Choose the paragraph that
				applies.
We have suspended our final review of your application. If,
				after careful consideration, you still believe this policy is what you want,
				check the appropriate box below and return this letter to us within the next 60
				days. We will then continue reviewing your application and issue a policy if
				you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				close your file and not issue you a policy. You should understand that you will
				not have any coverage until we hear back from you, approve your application and
				issue you a policy.
Please check one box and return in the enclosed
				envelope.
[]
Yes,
[although my worksheet indicates that
				long-term care insurance may not be a suitable purchase,] I wish to purchase
				this coverage. Please resume review of my application.
Note: Delete the phrase in brackets if the applicant
				did not answer the questions about income.
[]
No.
I have decided not to buy a policy at this
				time.
APPLICANT'S SIGNATURE
DATE
Please return to [issuer] at [address] by
				[date].
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-180, filed 11/24/08,
				  effective 12/25/08.
Reviser's note:
The brackets and enclosed
				  material in the text of the above section occurred in the copy filed by the
				  agency.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-185 - Sample claims denial reporting form

Current through Register Vol. 24-14, July 15, 2024
The following form for reporting claims denials must be used in
				this state.
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of
For the Reporting Year of
Company Name:
Due: June 30, annually
Company Address:
Company NAIC Number:
Contact Person:
Phone Number:
Line of Business:
Individual
Group
Instructions
The purpose of this form is to report all long-term care claim
				denials under in-force long-term care insurance policies. "Denied" means a
				claim that is not paid for any reason other than for claims not paid for
				failure to meet the waiting period or because of an applicable preexisting
				condition.
State Data
Nationwide
							 Data1
1
Total Number of Long-Term Care Claims Reported
2
Total Number of Long-Term Care Claims Denied/Not
							 Paid
3
Number of Claims Not Paid Due to Preexisting
							 Condition Exclusion
4
Number of Claims Not Paid Due to Waiting
							 (Elimination) Period Not Met
5
Net Number of Long-Term Care Claims Denied for
							 Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6
Percentage of Long-Term Care Claims Denied of Those
							 Reported (Line 5 Divided By Line 1)
7
Number of Long-Term Care Claim Denied Due to:
8
Long-Term Care Services Not Covered Under the
							 Policy2
9
Provider/Facility Not Qualified Under the
							 Policy3
10
Benefit Eligibility Criteria Not
							 Met4
11
Other
Footnotes:
1.
The nationwide data may be viewed as a more
							 representative and credible indicator where the data for claims reported and
							 denied for your state are small in number.
2.
Example -- Home health care claim filed under a
							 nursing home only policy.
3.
Example -- A facility that does not meet the minimum
							 level of care requirements or the licensing requirements as outlined in the
							 policy.
4.
Examples -- A benefit trigger not met, certification
							 by a licensed health care practitioner not provided, no plan of care.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-185, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-195 - Form for reporting replacement and lapse of long-term care insurance policies

Current through Register Vol. 24-14, July 15, 2024
The following form must be used in this state to report
				replacements and lapses of long-term care insurance.
Long-Term Care Insurance Replacement and Lapse Reporting
				Form
For the State of For the Reporting Year of
Company Name:
Due: June 30, Annually
Company Address:
Company NAIC Number:
Contact Person: Phone Number:
Instructions
The purpose of this form is to report on a statewide basis
				information regarding long-term care insurance policy replacements and lapses.
				Specifically, every issuer must maintain records for each [agent] [insurance
				producer] on that [agent's] [insurance producer's] amount of long-term care
				insurance replacement sales as a percent of the [agent's] [insurance
				producer's] total annual sales and the amount of lapses of long-term care
				insurance policies sold by the [agent] [insurance producer] as a percent of the
				[agent's] [insurance producer's] total annual sales. The tables below should be
				used to report the ten percent of the issuer's [agents] [insurance producers]
				with the greatest percentages of replacements and lapses.
Listing of the 10% of [Agents] [Insurance Producers] with
				the Greatest Percentage of Replacements
[Agent's] [Insurance Producer's] Name
Number of Policies Sold by This [Agent] [Insurance
							 Producer]
Number of Policies Replaced by This [Agent]
							 [Insurance Producer]
Number of Replacements as % of Number Sold by This
							 [Agent] [Insurance Producer]
Listing of the 10% of [Agents] [Insurance Producers] with
				the Greatest Percentage of Lapses
[Agent's] [Insurance Producer's] Name
Number of Policies Sold by This [Agent] [Insurance
							 Producer]
Number of Policies Lapsed by This [Agent] [Insurance
							 Producer]
Number of Lapses as % of Number Sold by This [Agent]
							 [Insurance Producer]
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales
				%
Percentage of Replacement Policies Sold to Policies In Force
				(as of the end of the preceding calendar year)%
Percentage of Lapsed Policies to Total Annual Sales%
Percentage of Lapsed Policies to Policies In Force (as of the
				end of the preceding calendar year) %
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-195, filed 11/24/08,
				  effective 12/25/08.
Reviser's note:
The brackets and enclosed
				  material in the text of the above section occurred in the copy filed by the
				  agency.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-210 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For purposes of WAC
				284-83-210 through
				284-83-250:
(1) "Actual loss ratio" means a retrospective
			 calculation and calculated as the benefits incurred divided by the "premiums
			 earned," both measured from the beginning of the calculating period to the date
			 of the loss ratio calculations.
(2)
			 "Benefits incurred" means the claims incurred plus any increase (or less any
			 decrease) in the reserves.
(3)
			 "Calculating period" means the time span over which the actuary expects the
			 premium rates, whether level or increasing, to remain adequate in accordance
			 with the actuary's best estimate of future experience and during which the
			 actuary does not expect to request a rate increase.
(4) "Claims incurred" means:
(a) Claims paid during the accounting period;
			 plus
(b) The change in the
			 liability for claims which have been reported but not paid; plus
(c) The change in the liability for claims
			 which have not been reported but which may reasonably be expected.
Claims incurred does not include expenses incurred in
				processing the claims, home office or field overhead, acquisition and selling
				costs, taxes or other expenses, contributions to surplus, or profit.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-220 - Grouping of policy forms for purposes of ratemaking and requests for rate increase

Current through Register Vol. 24-14, July 15, 2024
(1) The actuary
			 responsible for setting premium rates must group similar policy forms,
			 including forms no longer being marketed, in the pricing calculations.
(a) The grouping must be satisfactory to the
			 commissioner, who may rely on the judgment of the pricing actuary.
(b) Factors that must be considered include
			 similar claims experience, types of benefits, reserves, margins for
			 contingencies, expenses and profit, and equity between policyholders.
(c) A grouping must enhance statistical
			 reliability and improve the likelihood of premium adequacy without introducing
			 elements of discrimination in violation of
			 RCW
			  48.18.480.
(d) A grouping is not required to include
			 forms issued by health care service contractors or health maintenance
			 organizations before January 1, 1988.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-225 - Separation of data regarding certain policies

Current through Register Vol. 24-14, July 15, 2024
For reporting and record-keeping purposes, commencing with
				reports for accounting periods beginning on or after January 1, 2009, all
				issuers must separate data concerning long-term care insurance policies from
				data concerning other insurance policies.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-225, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-230 - Loss ratio requirements for long-term care insurance forms

Current through Register Vol. 24-14, July 15, 2024
The following standards and requirements apply to long-term
				care insurance forms:
(1) Benefits for
			 individual long-term care insurance forms will be deemed reasonable in relation
			 to the premiums if the overall loss ratio is at least sixty percent over a
			 calculating period chosen by the issuer and satisfactory to the
			 commissioner.
(2) Benefits for
			 group long-term care insurance forms will be deemed reasonable in relation to
			 the premiums if the overall loss ratio is at least seventy percent over a
			 calculating period chosen by the issuer and satisfactory to the
			 commissioner.
(3) The calculating
			 period may vary with the benefit and renewal provisions. The issuer may be
			 required to demonstrate the reasonableness of the calculating period chosen by
			 the actuary responsible for the premium calculations. A brief explanation of
			 the selected calculating period must accompany the filing.
(4) Policy forms, the benefits of which are
			 particularly exposed to the effects of inflation and whose premium income may
			 be particularly vulnerable to an eroding persistency and other similar forces,
			 must use a relatively short calculating period reflecting the uncertainties of
			 estimating the risks involved.
(a) Policy
			 forms based on more dependable statistics may employ a longer calculating
			 period.
(b) The calculating period
			 may be the lifetime of the policy for guaranteed renewable and noncancellable
			 policy forms if these forms provide benefits which are supported by reliable
			 statistics and which are protected from inflationary or eroding forces by such
			 factors as fixed dollar coverages, inside benefit limits, or the inherent
			 nature of the benefits.
(c) The
			 calculating period may be as short as one year for coverages that are based on
			 statistics of minimal reliability or which are highly exposed to
			 inflation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-240 - Experience records

Current through Register Vol. 24-14, July 15, 2024
Issuers must maintain records of earned premiums and incurred
				benefits for each policy year for each contract, rider, endorsement and similar
				form which is combined for purposes of premium calculations, including the
				reserves. Records must be maintained of the experience expected in the premium
				calculations. Notwithstanding the foregoing, with proper justification, the
				commissioner may accept approximation of policy year experience based on
				calendar year data.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-240, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-245 - Evaluating experience data

Current through Register Vol. 24-14, July 15, 2024
In determining the credibility and appropriateness of
				experience data, due consideration will be given by the commissioner to all
				relevant factors including:
(1)
			 Statistical credibility of premiums and benefits such as low exposure or low
			 loss frequency;
(2) Past and
			 projected trends relative to the kind of coverage, such as inflation in medical
			 expenses, economic cycles affecting disability income experience, inflation in
			 expense charges and others;
(3) The
			 concentration of experience at early policy durations where select morbidity
			 and preliminary term reserves are applicable and where loss ratios are expected
			 to be substantially higher or lower than in later policy durations;
(4) The mix of business by risk
			 classification;
(5) The expected
			 lapses and antiselection at the time of rate increases.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-245, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-250 - Life insurance policies that accelerate benefits for long-term care

Current through Register Vol. 24-14, July 15, 2024
(1) WAC
			 284-83-210 through
			 284-83-245 do not apply to life
			 insurance policies that accelerate benefits for long-term care.
(2) A life insurance policy that funds
			 long-term care benefits entirely by accelerating the death benefit is
			 considered to provide reasonable benefits in relation to premiums paid, if the
			 policy complies with all of the following provisions:
(a) The interest credited internally to
			 determine cash value accumulations, including long-term care, if any, are
			 guaranteed not to be less than the minimum guaranteed interest rate for cash
			 value accumulations without long-term care set forth in the policy;
(b) The portion of the policy that provides
			 life insurance benefits meets the nonforfeiture requirements of chapter 48.76
			 RCW;
(c) The policy meets the
			 disclosure requirements of
			 RCW
			  48.83.070(2) and
			 48.83.080;
(d) Any policy
			 illustration that meets the applicable requirements of the chapter 48.23A RCW;
			 and
(e) An actuarial memorandum is
			 filed with the insurance department that includes:
(i) A description of the basis on which the
			 long-term care rates were determined;
(ii) A description of the basis for the
			 reserves;
(iii) A summary of the
			 type of policy, benefits, renewability, general marketing method, and limits on
			 ages of issuance;
(iv) A
			 description and a table of each actuarial assumption used. For expenses, the
			 issuer must include percent of premium dollars per policy and dollars per unit
			 of benefits, if any;
(v) A
			 description and a table of the anticipated policy reserves and additional
			 reserves to be held in each future year for active lives;
(vi) The estimated average annual premium per
			 policy and the average issue age;
(vii) A statement as to whether underwriting
			 is performed at the time of application. The statement must indicate whether
			 underwriting is used and, if used, the statement must include a description of
			 the type or types of underwriting used, such as medical underwriting or
			 functional assessment underwriting. Concerning a group policy, the statement
			 must indicate whether the enrollee or any dependent will be underwritten and
			 when underwriting occurs; and
(viii) A description of the effect of the
			 long-term care policy provision on the required premiums, nonforfeiture values
			 and reserves on the underlying life insurance policy, both for active lives and
			 those in long-term care claim status.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-300 - Standards for protecting patient privacy rights

Current through Register Vol. 24-14, July 15, 2024
Issuers must adopt and use administrative, business, and
				operational practices and procedures designed to protect an insured's right to
				privacy granted under
				chapter
				70.02 RCW and federal laws
				and regulations. For example, issuers must not disclose the insured's health
				information without the written authorization of the insured, except where the
				recipient needs to know the information, such as:
(1) To any person, health care provider or
			 health care facility that the issuer reasonably believes is providing health
			 care to the insured;
(2) To any
			 other person who requires health care information to provide planning, quality
			 assurance, peer review, or administrative, legal, financial, billing or
			 actuarial services;
(3) To assist a
			 health care provider or health care facility in the delivery of health care and
			 the issuer reasonably believes that the recipient will not use or disclose the
			 health care information for any purpose other than the delivery of health care
			 and will take appropriate steps to protect the information;
(4) To a health care provider or health care
			 facility reasonably believed to have previously provided health care to the
			 insured to the extent necessary to provide health care services, unless the
			 insured has instructed the health care provider or health care facility in
			 writing not to make the disclosure.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-300, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-310 - Right of insureds to receive confidential health services

Current through Register Vol. 24-14, July 15, 2024
Issuers must adopt and use administrative, business, and
				operational practices and procedures to protect the insured's right to
				confidential health care services.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-310, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-320 - Standards for the issuer's timely review of a claim denial

Current through Register Vol. 24-14, July 15, 2024
The following administrative, business, and operational
				standards must be used by issuers to ensure timely review of a claim
				denial.
(1) Issuers must have a fully
			 operational, comprehensive claims denial review process.
(2) Issuers must implement procedures for
			 registering and responding to oral and written requests for review of a claim
			 denial in a timely and thorough manner.
(3) Issuers must provide written notice to
			 the insured, to the insured's designated representative, and to the insured's
			 provider of its decision to deny, modify, reduce, or terminate payment,
			 coverage, authorization, or provision of health care services or benefits,
			 including the admission to or continued stay in a health care facility or any
			 other long-term care services or benefits.
(4) Issuers must process as an appeal an
			 enrollee's written or oral request that the issuer reconsider its decision to
			 deny, modify, reduce, or terminate payment, coverage, authorization, or
			 provision of health care services or benefits, including the admission to, or
			 continued stay in, a health care facility. The issuer must not require that the
			 insured file a complaint prior to seeking appeal of any such
			 decision.
(5) The issuer must:
(a) Provide written notice to the insured
			 when the appeal is received;
(b)
			 Assist the insured with the appeal process;
(c) Make its decision regarding the appeal
			 within thirty days after the date the appeal is received, except when a
			 determination is made that the issuer's action must be expedited;
(d) Cooperate with a representative
			 authorized in writing by the insured;
(e) Consider all information submitted by the
			 insured;
(f) Investigate and
			 resolve the appeal; and
(g) Provide
			 written notice of its resolution of the appeal to the insured and, with the
			 permission of the insured, to the insured's providers, that:
(i) Explains the issuer's decision and the
			 supporting coverage or clinical reasons for the decision; and
(ii) If applicable, explains any further
			 appeal process, including, if applicable, information about how to exercise the
			 insured's rights to a second opinion and how to continue receiving or reinstate
			 services.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-325 - Prompt payment of clean claims

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of this section is to
			 effectuate
			 RCW
			  48.83.090 and
			 48.83.170 by establishing prompt
			 payment requirements for long-term care insurance.
(2) For purposes of this section, the
			 following definitions apply:
(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.
(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.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-350 - Standard applied if there is a conflict between a master policy and certificate of insurance

Current through Register Vol. 24-14, July 15, 2024
If there is a discrepancy between a description of the terms
				and conditions of insurance between the master policy and any certificate
				issued under that master policy, the description most favorable to the insured
				must be used by the issuer and governs the matter.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-350, filed 11/24/08,
				  effective 12/25/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-400 - Purpose and authority

Current through Register Vol. 24-14, July 15, 2024
WAC
				  284-83-400 through
				  284-83-420 is adopted pursuant to
				  RCW
				   48.85.030 and
				  48.85.040. The purpose of these
				  sections is to effectuate chapter 48.85 RCW, the Washington Long-Term Care
				  Partnership Act. Pursuant to
				  RCW
				   48.85.030, these sections establish minimum
				  standards and disclosure requirements to be met by insurers, health care
				  service contractors, health maintenance organizations, and fraternal benefit
				  societies with respect to long-term care partnership insurance policies to
				  include: Contracts, certificates, riders, and endorsements.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.85.030. 11-22-068 (Matter No. R
					 2011-08), §
											284-83-400, filed 10/31/11,
					 effective 12/1/11.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-405 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
(1) WAC
				284-83-400 through
				284-83-420 applies to any
				qualified long-term care insurance partnership policy, as defined by federal
				law and this chapter.
(2) These
				sections do not apply to medicare supplement policies regulated under chapters
				48.66 RCW and 284-55 or 284-66 WAC; policies or contracts between a continuing
				care retirement community and its residents; or to long-term care insurance
				policies that are not intended to provide asset protection under chapter 48.85
				RCW.
(3) Policies that do not meet
				the requirements of the Washington Long-Term Care Partnership Act and the
				requirements of this chapter may not be advertised, issued or delivered in this
				state as partnership policies.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.85.030. 11-22-068 (Matter No. R
					 2011-08), §
											284-83-405, filed 10/31/11,
					 effective 12/1/11.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-410 - Minimum standards for long-term care partnership policies

Current through Register Vol. 24-14, July 15, 2024
Every long-term care partnership policy must meet the standards for long-term care policies or contracts in chapters 48.83 and 48.85 RCW and this chapter, unless specifically provided otherwise.
(1) As used in WAC 284-83-400 through 284-83-420, "qualified long-term care partnership policy" or "partnership policy" means a long-term care policy that meets all of the following additional requirements:
(a) The policy was issued on or after January 1, 2012, or exchanged as provided in WAC 284-83-415 on or after January 1, 2012, and covers an insured who was a resident of this state or of another state that has entered into a reciprocal agreement with this state when coverage first became effective under the policy.
(b) The policy is a tax qualified long-term care insurance policy as defined in Section  7702B(b) of the Internal Revenue Code of 1986 (26 U.S.C. 7702 B(b)).
(c) The policy provides at least the following levels of inflation protection:
(i) If the policy is sold to an individual who has not attained age sixty-one as of the date of purchase, the policy must provide automatic annual compounded inflation increases at a rate not less than three percent or automatic annual compounded inflation increases at a rate based on changes in the consumer price index.
(ii) If the policy is sold to an individual who has attained age sixty-one but has not attained age seventy-six as of the date of purchase, the policy must provide automatic simple inflation increases at a rate not less than three percent or automatic inflation increases at a rate based on changes in the consumer price index.
(iii) If the policy is sold to an individual who has attained age seventy-six as of the date of purchase, the policy may, but is not required to, provide automatic inflation increases at a rate based on changes in the consumer price index.
(iv) If the change in the consumer price index is a negative number for the time period in question, the carrier may not apply the change in the index to reduce the benefit payable under the partnership policy. However, the carrier may offset this negative number against the next annual increase in the consumer price index to reduce the automatic inflation increase which would otherwise occur during that year. If the negative consumer price index exceeds the next annual increase in the consumer price index, it may be offset against multiple annual increases, the net effect of which may never be less than zero.
(v) For purposes of this section, "consumer price index" means the consumer price index for all urban consumers, U.S. city average, all items, as determined by the Bureau of Labor Statistics of the United States Department of Labor.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-415 - Long-term care partnership policy exchange or replacement

Current through Register Vol. 24-14, July 15, 2024
(1) Within one year
				of the date that an issuer begins to advertise, market, offer, or sell policies
				that qualify under the Washington state long-term care partnership program, the
				issuer must offer to all of its current policyholders and certificate holders
				the opportunity to exchange their existing long-term policy for a policy that
				is intended to qualify under the state's long-term care partnership program
				provided that:
(a) The existing long-term
				care policy was issued on or after February 8, 2006; and
(b) The existing long-term care policy is the
				type certified by the issuer for purposes of the state long-term care
				partnership program.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-420 - Reporting

Current through Register Vol. 24-14, July 15, 2024
All issuers of qualified long-term care partnership policies
				  must provide regular reports to the United States Secretary of Health and Human
				  Services in accordance with regulations of the secretary. These reports include
				  notification regarding when benefits provided under the policy have been paid
				  and the amount of such benefits paid, notification regarding when the policy
				  otherwise terminates, and such other information as the secretary determines
				  may be appropriate to the administration of partnership
				  policies.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.85.030. 11-22-068 (Matter No. R
					 2011-08), §
											284-83-420, filed 10/31/11,
					 effective 12/1/11.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › LONG-TERM CARE PARTNERSHIP PROGRAM › Section 284-83-425 - Producer education

Current through Register Vol. 24-14, July 15, 2024
Prior to selling, soliciting, or negotiating, or continuing
				  to sell, solicit, or negotiate long-term care partnership policies in this
				  state, all licensed producers must meet the education requirements in
				  RCW
				   48.83.130(2).
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.85.030. 11-22-068 (Matter No. R
					 2011-08), §
											284-83-425, filed 10/31/11,
					 effective 12/1/11.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-84 - Fixed premium universal life insurance › Section 284-84-010 - Scope

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter
			 applies to all insurers and to every individual fixed premium universal life
			 insurance policy form, as defined in this regulation, whether solicited on an
			 individual or mass-marketing basis, filed for approval after August 31,
			 1986.
(2) The approval of
			 individual fixed premium universal life insurance policy forms approved,
			 whether affirmatively approved or deemed approved, prior to September 1, 1986,
			 and which are not in compliance with the provisions of this regulation on
			 January 1, 1987, is hereby withdrawn as of January 1, 1987, and such forms
			 shall not thereafter be delivered or issued for delivery in this
			 state.
(3) This chapter defines
			 unfair practices and disclosure requirements in connection with the separate
			 accumulation of policy values granted in a rider and attached to, granted in a
			 separate policy provision or incorporated in fixed premium universal life
			 insurance policy forms. This chapter does not define minimum nonforfeiture
			 provisions for the separate accumulation of funds or policy values attached to,
			 separately granted or incorporated in fixed premium universal life insurance
			 policy forms.
(4) This chapter does
			 not apply to universal life insurance policies where the interest credits are
			 linked to an external referent.
(5)
			 This chapter does not apply to policy forms defined under
			 chapter
			 48.18A RCW.
Statutory Authority:
				  RCW
				  48.02.060. 86-02-011 (Order R 85-5), §
										284-84-010, filed
				  12/20/85.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-84 - Fixed premium universal life insurance › Section 284-84-020 - Definitions

Current through Register Vol. 24-14, July 15, 2024
As used in this regulation:
(1) "Universal life insurance policy" means
			 any individual life insurance policy having provisions for separately
			 identified interest credits (other than in connection with dividend
			 accumulations, premium deposit funds, or other supplementary accounts) and
			 mortality and expense charges. A universal life insurance policy may provide
			 for other credits and charges, such as charges for the cost of benefits
			 provided by rider.
(2) "Flexible
			 premium universal life insurance policy" means a universal life insurance
			 policy which permits the policyowner to vary the amount or timing of one or
			 more premium payments or the amount of insurance, independently of each
			 other.
(3) "Fixed premium universal
			 life insurance policy" means a universal life insurance policy other than a
			 flexible premium universal life insurance policy. These policies typically
			 schedule a guaranteed maximum premium at the beginning of each policy year for
			 the premium paying period.
(4)
			 "Cash surrender value" means the amount available in cash to the policyowner
			 upon surrender of the policy, in the absence of any indebtedness.
(5) "Net cash surrender value" means the cash
			 surrender value less any indebtedness under the policy.
(6) "Policy value" means the amount,
			 developed within the main structure of the policy or provided in a separate
			 policy provision, to which separately identified interest credits and
			 mortality, morbidity, expense or other charges are made under a fixed premium
			 universal life insurance policy. The policy owner may or may not have a right
			 to the entire policy value because of built in surrender charges imposed by the
			 insurer.
(7) "Substandard class of
			 insureds" is one whose mortality rates are assumed to be higher than the
			 mortality rates employed with standard issues according to the insurer's
			 classification of risks.
(8) "Death
			 benefit corridor" defines a minimum policy benefit payable in addition to its
			 cash value in the event of the death of the insured.
Statutory Authority:
				  RCW
				  48.02.060. 86-02-011 (Order R 85-5), §
										284-84-020, filed
				  12/20/85.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-84 - Fixed premium universal life insurance › Section 284-84-030 - Commissioner's reserve valuation method

Current through Register Vol. 24-14, July 15, 2024
The minimum valuation standard for universal life insurance
				policies shall be the commissioners reserve valuation method, as hereinafter
				described for such policies, and the tables and interest rates hereinafter
				specified. The terminal reserve for the basic policy and any benefits and/or
				riders for which premiums are not paid separately as of any policy anniversary
				shall be equal to the net level premium reserves less (C) and less (D),
				where:
(1) Reserves by the net level
			 premium method shall be equal to ((A)-(B))r where:
(a)
(A) is
			 the present value of all future guaranteed benefits at the date of
			 valuation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-84 - Fixed premium universal life insurance › Section 284-84-040 - Alternate minimum reserves

Current through Register Vol. 24-14, July 15, 2024
(1) If,
			 in any policy year, the guaranteed maturity premium on any universal life
			 insurance policy is less than the valuation net premium for such policy,
			 calculated by the valuation method actually used in calculating the reserve
			 thereon but using the minimum valuation standards of mortality and rate of
			 interest, the minimum reserve required for such contract shall be the greater
			 of (a) or (b) of this subsection:
(a) The
			 reserve calculated according to the method, the mortality table, and the rate
			 of interest actually used.
(b) The
			 reserve calculated according to the method actually used but using the minimum
			 valuation standards of mortality and rate of interest and replacing the
			 valuation net premium by the guaranteed maturity premium in each policy year
			 for which the valuation net premium exceeds the guaranteed maturity
			 premium.