Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 1

Current through June 24, 2024
(COMPANY NAME)
OUTLINE OF COVERAGE
(Insert the appropriate caption stated below.)
1. This policy is [an individual policy of insurance] ([a group
				policy] that was issued in the [indicate jurisdiction in which group policy was
				issued]).
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage
				provides a very brief description of the important features of the policy. You
				should compare this outline of coverage to outlines of coverage for other
				policies available to you. This is not an insurance contract, but only a
				summary of coverage. Only the individual or group policy contains governing
				contractual provisions. This means that the policy or group policy sets forth
				in detail the rights and obligations of both you and the insurance company.
				Therefore, if you purchase this coverage, or any other coverage, it is
				important that you READ YOUR POLICY (OR CERTIFICATE) CAREFULLY!
3. FEDERAL TAX CONSEQUENCES.
This [POLICY] [CERTIFICATE] is intended to be a federally
				tax-qualified long-term care insurance contract under Section 7702B(b) of the
				Internal Revenue Code of 1986, as amended.
OR
Federal Tax Implications of this [POLICY] [CERTIFICATE]. This
				[POLICY] [CERTIFICATE] is not intended to be a federally tax-qualified
				long-term care insurance contract under Section 7702B(b) of the Internal
				Revenue Code of 1986 as amended. Benefits received under the [POLICY]
				[CERTIFICATE] may be taxable as income.
4. Terms Under Which the Policy OR Certificate May Be Continued
				in Force or Discontinued.
(a) [For long-term care insurance policies or certificates
				describe one of the following permissible policy renewability
				provisions:
(1) Policies and certificates that are guaranteed renewable
				shall contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE]
				IS GUARANTEED RENEWABLE. This means you have the right, subject to the terms of
				your policy, [certificate] to continue this policy as long as you pay your
				premiums on time. [Company Name] cannot change any of the terms of your policy
				on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU
				PAY.
(2) [Policies and certificates that are noncancellable shall
				contain the following statement:] RENEWABILITY: THIS POLICY [CERTIFICATE] IS
				NONCANCELLABLE. This means that you have the right, subject to the terms of
				your policy, to continue this policy as long as you pay your premiums on time.
				[Company Name] cannot change any of the terms of your policy on its own and
				cannot change the premium you currently pay. However, if your policy contains
				an inflation protection feature where you choose to increase your benefits,
				[Company Name] may increase your premium at that time for those additional
				benefits.
(b) [For group coverage, specifically describe
				continuation/conversion provisions applicable to the certificate and group
				policy;]
(c) [Describe waiver of premium provisions or state that there
				are not such provisions.]
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
[In bold type larger than the maximum type required to be used
				for the other provisions of the outline of coverage, state whether or not the
				company has a right to change the premium, and if a right exists, describe
				clearly and concisely each circumstance under which the premium may
				change.]
6. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED
				AND PREMIUM REFUNDED.
(a) [Provide a brief description of the right to return- "free
				look" provision of the policy.]
(b) [Include a statement that the policy either does or does
				not contain provisions providing for a refund or partial refund of premium upon
				the death of an insured or surrender of the policy or certificate. If the
				policy contains such provisions, include a description of them.]
7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are
				eligible for Medicare, review the Medicare Supplement Buyer's Guide available
				from the insurance company.
(a) [For agents] Neither [insert company name] nor its agents
				represent Medicare, the federal government or any state government.
(b) [For direct response] [insert company name] is not
				representing Medicare, the federal government or any state government.
8. LONG-TERM CARE COVERAGE. Policies of this category are
				designed to provide coverage for one or more necessary or medically necessary
				diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal
				care services, provided in a setting other than an acute care unit of a
				hospital, such as in a nursing home, in the community or in the home.
This policy provides coverage in the form of a fixed dollar
				indemnity benefit for covered long-term care expenses, subject to policy
				[limitations] [waiting periods] and [coinsurance] requirements. [Modify this
				paragraph if the policy is not an indemnity policy.]
9. BENEFITS PROVIDED BY THIS POLICY.
(a) [Covered services, related deductibles, waiting periods,
				elimination periods and benefit maximums.]
(b) [Institutional benefits, by skill level.]
(c) [Non-institutional benefits, by skill level.]
(d) Eligibility for Payment of Benefits
[Activities of daily living and cognitive impairment shall be
				used to measure an insured's need for long-term care and shall be defined and
				described as part of the outline of coverage.]
[Any additional benefit triggers shall also be explained. If
				these triggers differ for different benefits, explanation of the triggers shall
				accompany each benefit description. If an attending physician or other
				specified person shall certify a certain level of functional dependency in
				order to be eligible for benefits, this too shall be specified.]
10. LIMITATIONS AND EXCLUSIONS.
[Describe:
(a) Preexisting conditions;
(b) Non-eligible facilities and providers;
(c) Non-eligible levels of care (e.g., unlicensed providers,
				care or treatment provided by a family member, etc.);
(d) Exclusions and exceptions;
(e) Limitations.]
[This section should provide a brief specific description of
				any policy provisions which limit, exclude, restrict, reduce, delay, or in any
				other manner operate to qualify payment of the benefits described in Number 9
				above.]
THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR
				LONG-TERM CARE NEEDS.
11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the
				costs of long-term care services will likely increase over time, you should
				consider whether and how the benefits of this plan may be adjusted. [As
				applicable, indicate the following:
(a) That the benefit level will not increase over time;
(b) Any automatic benefit adjustment provisions;
(c) Whether the insured will be guaranteed the option to buy
				additional benefits and the basis upon which benefits will be increased over
				time if not by a specified amount or percentage;
(d) If there is such a guarantee, include whether additional
				underwriting or health screening will be required, the frequency and amounts of
				the upgrade options, and any significant restrictions or limitations;
(e) And finally, describe whether there will be any additional
				premium charge imposed, and how that is to be calculated.]
12. ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN
				DISORDERS.
[State that the policy provides coverage for insureds
				clinically diagnosed as having Alzheimer's disease or related degenerative and
				dementing illnesses. Specifically describe each benefit screen or other policy
				provision that provides preconditions to the availability of policy benefits
				for such an insured.]
13. PREMIUM.
[(a) State the total annual premium for the policy;
(b) If the premium varies with an applicant's choice among
				benefit options, indicate the portion of annual premium that corresponds to
				each benefit option.]
14. ADDITIONAL FEATURES.
[(a) Indicate if medical underwriting is used;
(b) Describe other important features.]
15. CONTACT THE WISCONSIN SENIOR HEALTH INSURANCE INFORMATION
				PROGRAM OR YOUR COUNTY BENEFIT SPECIALIST IF YOU HAVE GENERAL QUESTIONS
				REGARDING LONG-TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF YOU HAVE
				SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE POLICY OR
				CERTIFICATE.