Ins 3.46(4)(d)3. 3. Days for which Medicare provides coverage are counted for the purpose of determining expiration of the elimination period; and
Ins 3.46(4)(d)4. 4. It does not exceed 365 days.
Ins 3.46(4)(e) (e) Provide for a lifetime maximum limit only if the limit provides not less than 365 days of coverage. Only days of coverage under the policy, coverage or certificate may be applied against a lifetime maximum limit. Coverage by Medicare may not be applied against a lifetime maximum limit.
Ins 3.46(4)(f) (f) Clearly disclose that it does not cover duplicate payments by Medicare for nursing home care or home health care if it has either exclusion.
Ins 3.46(4)(g) (g) Provide coverage regardless of whether care is medically necessary. Coverage shall be triggered in conformance with the provisions contained in subs. (17) and (18).
Ins 3.46(4)(h) (h) Not limit or condition coverage or benefits by requiring prior hospitalization or prior receipt of care, or benefits for care, in an institutional setting.
Ins 3.46(4)(i) (i) Cover irreversible dementia. Coverage may not be excluded or limited on the basis of irreversible dementia.
Ins 3.46(4)(j) (j) Define terms used to describe covered services, including, but not limited to, "skilled nursing care," extended care facility," "convalescent nursing home," "personal care," or "home care" services, if those terms are used, in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services. When the definition requires that the provider be appropriately licensed, certified or registered, it shall also state what requirements a provider shall meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the state licenses, certifies or registers the providers of services under another name.
Ins 3.46(4)(k) (k) All providers of services, including, but not limited to, "skilled nursing facility," "extended care facility," "convalescent nursing home," "personal care facility," "specialized care providers," "assisted living," and "home care agency," shall be defined in relation to the services and facilities required to be available and the licensure, certification, registration or degree status of those providing or supervising the services in the state where the policy was issued. When the definition requires that a provider be appropriately licensed, certified or registered, it shall also state what requirements a provider shall meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of such services to be licensed, certified or registered, or if the state licenses, certifies or registers the provider of services under another name.
Ins 3.46(4)(m) (m) Not exclude or limit coverage by type of illness, treatment, medical condition or accident, except it may include exclusions or limits for any of the following:
Ins 3.46(4)(m)1. 1. Preexisting conditions or diseases. If a long-term care insurance policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy and shall be labeled as "Preexisting Condition Limitations."
Ins 3.46(4)(m)2. 2. Illness, treatment or medical condition arising out of any one or more of the following:
Ins 3.46(4)(m)2.a. a. Treatment provided in a government facility, unless otherwise required by law.
Ins 3.46(4)(m)2.b. b. Services for which benefits are available under Medicare or other governmental programs, except Medicaid, or under a state or federal worker's compensation, employer's liability, occupational disease law, or any motor vehicle no-fault law.
Ins 3.46(4)(m)2.c. c. Services provided by a member of the insured's immediate family or for which no charge is normally made in the absence of insurance.
Ins 3.46(4)(m)2.d. d. War or act of war, whether declared or undeclared.
Ins 3.46(4)(m)2.e. e. Participation in a felony, riot or insurrection.
Ins 3.46(4)(m)2.f. f. Service in the armed forces or its auxiliary units.
Ins 3.46(4)(m)2.g. g. Suicide, sane or insane, attempted suicide or intentionally self-inflicted injury.
Ins 3.46(4)(m)2.h. h. Aviation, however, this exclusion applies only to non-fare-paying passengers.
Ins 3.46(4)(m)3. 3. Mental or nervous disorders; however, this may not permit exclusion or limitation of benefits on the basis of Alzheimer's Disease.
Ins 3.46(4)(m)4. 4. Alcoholism or drug addiction.
Ins 3.46(4)(m)5. 5. Expenses for services or items available or paid under another long-term care insurance or health insurance policy.
Ins 3.46(4)(m)6. 6. This paragraph is not intended to prohibit exclusions or limitation by type of provider. In this subdivision, "state of policy issue" means the state in which the individual policy or certificate was originally issued. However, no long-term care insurer may deny a claim because services are provided in a state other than the state of policy issue when either of the following conditions occurs:
Ins 3.46(4)(m)6.a. a. When a state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but where the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification or registration.
Ins 3.46(4)(m)6.b. b. When a state other than the state of policy issue licenses, certifies or registers the provider under another name.
Ins 3.46(4)(m)7. 7. This paragraph is not intended to prohibit territorial limitations.
Ins 3.46(4)(m)8. 8. If payment of benefits is based on standards described as "usual and customary," "reasonable and customary" or words of similar import shall include a definition of these terms and include an explanation of the terms in its accompanying outline of coverage and comply with s. Ins 3.60 (5).
Ins 3.46(4)(m)9. 9. In the case of a qualified long-term care insurance contract, expenses for services or items to the extent that the expenses are reimbursable under Medicare or would be so reimbursable but for the application of a deductible or coinsurance amount.
Ins 3.46(4)(m)10. 10. Subject to the policy provisions, any plan of care required under the policy shall be provided by a licensed health care practitioner and does not require insurer approval. The insurer may provide a predetermination of benefits payable pursuant to the plan of care. This does not prevent the insurer from having discussions with the licensed health care practitioner to amend the plan of care. The insurer may also retain the right to verify that the plan of care is appropriate and consistent with generally accepted standards.
Ins 3.46(4)(m)11. 11. A long-term care policy containing post-confinement, post-acute care, or recuperative benefits shall include in a separate policy provision entitled "Limitation or Conditions on Eligibility for Benefits," the limitations or conditions applicable to these benefits, including any required number of days of confinement.
Ins 3.46(4)(n) (n) Not exclude or limit any coverage of care provided in a community-based setting, including, but not limited to, coverage of home health care, by any of the following:
Ins 3.46(4)(n)1. 1. Requiring that care be medically necessary.
Ins 3.46(4)(n)2. 2. Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services before community-based care is covered.
Ins 3.46(4)(n)3. 3. Limiting eligible services to services provided by registered nurses or licensed practical nurses.
Ins 3.46(4)(n)4. 4. Requiring that the insured have an acute condition before community-based care is covered.
Ins 3.46(4)(n)5. 5. Limiting benefits to services provided by Medicare certified agencies or providers.
Ins 3.46(4)(o) (o) Provide substantial scope of coverage of facilities for any benefits it provides for care in an institutional setting.
Ins 3.46(4)(p) (p) Provide substantial scope of coverage of facilities and programs for any benefits it provides for care in a community-based setting.
Ins 3.46(4)(q) (q) Contain a description of the benefit appeal procedure and comply with s. 632.84, Stats.
Ins 3.46(4)(r) (r) If coverage of care in a community-based setting is included, provide coverage of all types of care provided by state licensed or Medicare certified home health care agencies. A long-term care insurance policy may not, if it provides benefits for home health care or community care services limit or exclude benefits by any of the following acts:
Ins 3.46(4)(r)1. 1. Requiring that the insured or claimant would need care in a skilled nursing facility if home health care services were not provided.
Ins 3.46(4)(r)2. 2. 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 is covered.
Ins 3.46(4)(r)3. 3. 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.
Ins 3.46(4)(r)4. 4. Excluding coverage for personal care services provided by a home health aide.
Ins 3.46(4)(r)5. 5. 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.
Ins 3.46(4)(r)6. 6. Requiring that the insured or claimant have an acute condition before home health care services are covered.
Ins 3.46(4)(r)7. 7. Limiting benefits to services provided by Medicare-certified agencies or providers.
Ins 3.46(4)(r)8. 8. Excluding coverage for adult day care services.
Ins 3.46(4)(s) (s) If coverage of care in an institutional setting is provided, not condition eligibility for coverage of custodial or intermediate care on the concurrent or prior receipt of intermediate or skilled care.
Ins 3.46(4)(t) (t) Include a provision which allows for reinstatement of coverage, in the event of lapse, if the insurer is provided proof of cognitive impairment or the loss of functional capacity and if the reinstatement of coverage is requested within 5 months after termination and provision is made for the collection of past due premiums, where appropriate. The standard of proof of cognitive impairment or loss of functional capacity to be used in evaluating an application for reinstatement may not be more stringent than the benefit eligibility criteria on cognitive impairment or the loss of functional capacity, if any, contained in the policy and certificate.
Ins 3.46(4)(u) (u) Require a signed acceptance by the individual insured for all riders or endorsements added to an individual long-term care insurance policy after the date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy, except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy. After the date of issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, except if the increased benefits or coverage are required by law. Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium charge shall be set forth in the policy, rider, or endorsement.
Ins 3.46(5) (5)Form requirements for long-term care, nursing home and home health care policies only.
Ins 3.46(5)(a)(a) This subsection and ss. Ins 3.13 (2) (j) and 3.39 (9) (a) and ss. 632.76 and 632.897, Stats., do not apply to life insurance-long-term care coverage.
Ins 3.46(5)(b) (b) A form for long-term care policy or certificate shall:
Ins 3.46(5)(b)1. 1. Comply with the restrictions on preexisting condition provisions under s. 632.76, Stats.
Ins 3.46(5)(b)2. 2. Include the unrestricted right to return the policy or certificate within 30 days of the date it is received by the policyholder and comply with s. 632.73 (2m), Stats.
Ins 3.46(5)(b)3. 3. If it is a policy or certificate which covers care in both institutional and community-based settings, contain a caption as follows:
THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR LONG-TERM CARE INSURANCE.
THIS POLICY MEETS THOSE STANDARDS. THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME AND HOME HEALTH CARE SERVICES. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE "GUIDE TO LONG-TERM CARE" GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY'S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)4. 4. If it is a policy or certificate which covers care only in an institutional setting, contain a caption as follows:
THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR NURSING HOME INSURANCE. THIS POLICY MEETS THOSE STANDARDS.
THIS POLICY COVERS CERTAIN TYPES OF NURSING HOME CARE. THIS POLICY DOES NOT COVER HOME HEALTH CARE. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE "GUIDE TO LONG-TERM CARE" GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY'S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)5. 5. If it is a policy or certificate which covers care in a community setting only, contain a caption as follows:
THE WISCONSIN INSURANCE COMMISSIONER HAS ESTABLISHED MINIMUM STANDARDS FOR HOME HEALTH CARE INSURANCE. THIS POLICY MEETS THOSE STANDARDS.
THIS POLICY COVERS CERTAIN TYPES OF HOME HEALTH CARE. THIS POLICY DOES NOT COVER NURSING HOME CARE. THERE MAY BE LIMITATIONS ON THE SERVICES COVERED. READ YOUR POLICY CAREFULLY.
FOR MORE INFORMATION ON LONG-TERM CARE SEE THE "GUIDE TO LONG-TERM CARE" GIVEN TO YOU WHEN YOU APPLIED FOR THIS POLICY. THIS POLICY'S BENEFITS ARE NOT RELATED TO MEDICARE.
Ins 3.46(5)(b)6. 6. Contain the caption required under subd. 3., 4. or 5. imprinted on the face of the policy or certificate in type not smaller than 18-point and either in contrasting color from the text or with a distinctly contrasting background which is at least as prominent as contrasting color.
Ins 3.46(5)(b)7. 7. Include an extension of benefits provision which provides that if the policy is terminated for any reason, including, but not limited to, failure to pay premium, any benefits provided for care in an institutional setting will continue to be payable for institutionalization if the institutionalization begins when the policy is in force and continues without interruption after termination. This extension of benefits may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits and may be subject to any policy elimination period and all other applicable provisions of the policy.
Ins 3.46(5)(b)8. 8. If it is an individual policy, be plainly printed in black or blue ink in a uniform type of a style in general use with not less than 10-point with a lower case unspaced alphabet length not less than 120-point. If it is a group policy, certificates issued under the policy shall be plainly printed in black or blue ink in a uniform type of a style in general use, not less than 10-point with a lower case unspaced alphabet length not less than 120-point.
Ins 3.46(5)(b)9. 9. If it is an individual policy, include a provision which provides that the policy is guaranteed renewable for life or noncancellable, then such provision shall be appropriately captioned and shall appear on the first page of the policy and shall include any reservation by the insurer of the right to change premiums and any automatic renewal premium increase based on the policyholder's age.
Ins 3.46(6) (6)Nursing home and home health care coverage forms may not use the term "long-term care". Only a form for a long-term care policy, life insurance-long-term care coverage or certificate which provides substantial coverage of care in both an institutional setting and in a community-based setting may use the term "long-term care" or a substantially similar term.
Ins 3.46(7) (7)Misrepresentations prohibited.
Ins 3.46(7)(a)(a) No insurer or intermediary may use the term "long-term care" or similar terminology in an advertisement or offer of a policy, coverage or certificate unless the policy, coverage or certificate advertised or offered:
Ins 3.46(7)(a)1. 1. Covers care in both institutional and community-based settings;
Ins 3.46(7)(a)2. 2. Complies with this section; and
Ins 3.46(7)(a)3. 3. Is approved as a long-term care policy or certificate covering care in both institutional and community settings and as appropriately using the term "long-term care" by the office.
Ins 3.46(7)(b) (b) No insurer may file a form under s. 631.20, Stats., for a long-term care policy, life insurance-long-term care coverage or certificate, unless the form complies with this section.
Ins 3.46(8) (8)Outline of coverage.
Ins 3.46(8)(a)(a) An outline of coverage for a long-term care policy, life insurance-long-term care coverage or certificate shall:
Ins 3.46(8)(a)1. 1. Have captions printed in 18-point bold letters and conspicuously placed;
Ins 3.46(8)(a)2. 2. Be printed in an easy to read type and written in easily understood language; and
Ins 3.46(8)(b) (b) No insurer or intermediary may use an outline of coverage to comply with sub. (9) or advertise, market or offer a long-term care policy, life insurance-long-term care coverage or certificate, unless prior to the use, advertising, marketing or offer the outline of coverage is approved in writing by the office.
Ins 3.46(8)(c) (c) Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy all of the following:
Ins 3.46(8)(c)1. 1. "Notice to Buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations."
Ins 3.46(8)(c)2. 2. A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation by the insurer of the right to change premium. Continuation or conversion provisions of group coverage shall be specifically described.
Loading...
Loading...
Published under authority of s. 35.93, Stats. Updated on the first day of each month. Entire code is alwaycurrent. The date shown on each chapter is the date the chapter was last published.