Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-350 - Form to be used - Long-term care insurance disclosure form

Current through Register Vol. 24-14, July 15, 2024
No later than January 1, 1996, the disclosure form shall be
				substantially as follows:
(Company Name)
Disclosure Form
Long-term Care Insurance
The decision to buy a new long-term care policy is very
				important. It should be carefully considered.
The following data give you some general tips and furnish you
				with a summary of benefits available under our policy.
Your long-term care policy provides thirty days (sixty days for
				direct response insurers) within which you may decide without cost whether you
				wish to keep it. For your own information and protection, you should be aware
				of and seriously consider certain factors which may affect the insurance
				protection available under your policy.
If you now have insurance which provides benefits for long-term
				care,
read your policy carefully.
Look for what is
				said about renewing it. See if it contains waiting periods before benefits are
				paid. Note how it covers preexisting conditions (health conditions you already
				have). Compare these features with similar ones in any new policy. Use this
				information to measure the value of any insurance or health care plans you now
				have.
DON'T BUY MORE INSURANCE THAN YOU REALLY NEED. One policy that
				meets your needs is usually less expensive than several limited
				policies.
If you are eligible for state medical assistance coupons
				(medicaid), you should not purchase a long-term care insurance policy.
After you receive your policy, make sure you have received the
				coverage you thought you bought. If you are not satisfied with the policy, you
				may return it within thirty days (sixty days for direct response insurer) for a
				full refund of premium.
LTC DISCLOSURE FORM
1. INSTITUTIONAL CARE
What levels of care are covered by the
							 policy?
YES
NO
Does the policy provide benefits for these levels of
							 care?
Skilled Nursing Care?
Intermediate Nursing Care?
Custodial/Personal Care?
(By state law, all long-term care policies in
							 Washington State must cover all
three of the above levels of care.)
Where can care be received and be covered under
							 the policy?
Does the policy pay for care in
any
licensed facility?
If no, define the restrictions on where care can be
							 obtained:
Is the alternative plan of care benefit available
							 with institutional part of policy?
If yes, see section 2
Does the alternative plan of care benefit include
							 home care?
If yes, see section 2
Does the alternative plan of care benefit include
							 structural home improvements?
2. HOME/COMMUNITY BASED CARE
What types of care are covered by the
							 policy?
Does the policy provide home care benefit
							 for:
Check all that apply
Adult day care
Adult day health care
Chore services
Home health aides
Homemaker services
Hospice
Hygiene/personal care
Laboratory services
Meals/nutrition services
Medical equipment/supplies
Prescription drugs
Physician/nursing services
Respite care
Social workers
Therapies (List)
Transportation
Other:
Are these separate or post-confinement
							 benefits?
Separate
Post - Confinement
Where can home/community-based care be
							 received?
Check all that apply
Adult day care centers
Alternative care facilities
Assisted living facilities
Boarding homes
Community centers
Congregate care facilities
Multiple family residences
Single family residences
Other:
Does the alternative plan of care benefit
							 include home care?
Does the alternative plan of care benefit
							 include structural improvements?
Must the alternative plan of care be
							 pre-certified?
If yes, by whom?
3. BOTH INSTITUTIONAL AND COMMUNITY-BASED
							 CARE
What is the maximum daily benefit amount
							 for:
YES/NO/COMMENTS
Institutional/nursing home care?
Home/Community Based Care?
Are there limits on the number of days (or visits)
							 per year for which
benefits will be paid for:
Institutional/nursing home care?
Home/Community based care?
What are the dollar limits the policy will pay
							 during the policyholder's lifetime for:
Institutional/Nursing home care?
Home/Community based care?
Total lifetime limit?
What basic features and benefits does the
							 policy offer?
Is the policy guaranteed renewable?
Can you purchase additional increments of coverage?
							 If yes:
When can additional coverage be purchased?
How much can be purchased?
When is additional coverage no longer available for
							 purchase?
Does the policy have inflation
							 protection?
If yes, what is the % amount of the increase?
Is the rate of increase simple or compound?
When do increases stop?
If policy includes inflation coverage, what is
							 the daily benefit for:
Institutional/nursing home care.
5 years from policy effective date?
10 years from policy effective date?
Home/Community based care.
5 years from policy effective date?
10 years from policy effective date?
After the limits have been reached for
							 inflation adjustments, what is the maximum
daily benefit for:
Institutional/nursing home care
Home/community based care
After the limits have been reached for
							 inflation adjustments, what is the maximum
lifetime benefit for:
Institutional/nursing home care
Home/community based care
Is there a waiver of premium provision
							 for:
Institutional/nursing home care?
Home/community based care?
How many days of confinement in an institution are
							 required before the waiver of
premium benefit is available?
How many days of confinement at home are required
							 before the waiver of premium
benefit is available?
How many days of benefits must be paid before waiver
							 is effective?
Does the policy have a nonforfeiture
							 benefit?
If yes, how many years must policy be in effect
							 before the insured benefits from
nonforfeiture values?
What would the benefit value be in terms of dollars
							 after 20 years?
What does the nonforfeiture benefit promise? (give
							 an appropriate example showing
dollars and time limits)
Does the policy have a death
							 benefit?
If yes, specify value (in dollars of %)
What conditions or limitations apply, if any?
Does the policy have a restoration of benefits
							 provision?
If yes, give amount of benefit and minimum required
							 # of days between benefits.
If disability recurs, is there a new elimination or
							 waiting period before benefits
begin again?
If yes, after how long?
How long is the waiting period for preexisting
							 conditions?
How is the preexisting condition defined?
When do benefits begin?
How long is the elimination or waiting period before
							 benefits begin for:
Institutional/nursing home care?
Home/community based care?
What gatekeepers are required before benefits
							 start?
Doctor certification
Case management
If yes, by whom?
Medical necessity
Plan of treatment
If yes, by whom?
Inability to perform activities of daily living
							 (ADLs)
If yes, how many ADLs must fail before benefits
							 begin?
If the policy uses an ADL gatekeeper(s), define
							 "inability to perform ADL."
Is there a separate benefit qualification
							 requirement if there is a cognitive impairment?
Who determines a qualifying event?
Define any separate benefit qualification
							 requirement if there is a cognitive impairment:
What does the policy cost?
How often can the premium
							 increase?
By how much annually can the premium
							 increase?
Is there a discount if both spouses buy
							 policies?
If so, how much?
Do you lose the discount if one spouse dies?
4. ADDITIONAL POLICY INFORMATION
Use this space to outline additional benefits,
							 further explanations or clarifications
5.
POLICY
							 DEFINITIONS
(Include definitions of policy provisions)
WHAT DOES THE POLICY COST?
COMPANY NAME
. . . . . . ..
POLICY OPTION 1
POLICY OPTION 2
POLICY OPTION 3
POLICY OPTION 4
ELIMINATION (DEDUCTIBLE) PERIOD
BENEFIT PERIOD
$ BENEFIT FOR DAY
$ MAXIMUM BENEFIT
Institutional/Nursing Home
Home Health/Community Based
PREMIUM SUBTOTAL $
OPTIONAL BENEFITS
Inflation
Non Forfeiture
Spousal Discount
Death Benefit
Other
Other
Other
PREMIUM TOTAL $
BENEFIT "TRIGGERS"
(QUALIFICATION REQUIREMENTS)
List
List
List
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030 and
				  48.84.050. 95-19-028 (Order R
				  95-5), §
										284-54-350, filed 9/11/95,
				  effective 10/12/95. Statutory Authority:
				  RCW
				   48.02.060(3), 48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-350, filed
				  7/9/87.