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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. - See PDF for table PDF
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.
INS 3.46 Appendix 10
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 insurer shall maintain records for each agent on that agent's amount of long-term care insurance replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's agents with the greatest percentages of replacements and lapses.
Listing of the 10% of Agents with the Greatest Percentage of Replacements - See PDF for table PDF
Listing of the 10% of Agents with the Greatest Percentage of Lapses - See PDF for table PDF
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) ____%
Ins 3.465 Ins 3.465Wisconsin long-term care partnership program.
Ins 3.465(1)(1)General applicability. The provisions within s. Ins 3.46 regarding insurance transactions for long-term care and life insurance policies with long-term care provisions apply to insurance transactions described within this section.
Ins 3.465(2) (2)Definitions. The definitions contained in ss. Ins 3.455 and 3.46 also apply in this section. In addition, the following definitions apply in this section:
Ins 3.465(2)(a) (a) "Automatic exchange" means the issuance of a notice from an insurer informing an existing insured that the policy the insured purchased prior to January 1, 2009, from the insurer has been approved by the commissioner as a policy that meets the requirements of the state's partnership program and, as such, the policy will be treated from the date of the notice as a qualifying partnership policy.
Ins 3.465(2)(b) (b) "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.
Ins 3.465(2)(c) (c) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" means an individual or group insurance long-term care, nursing home or home health care contract that meets the requirements of section 7702B(b) of the Internal Revenue Code of 1986, as amended, or the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of sections 7702B(b) and (c) of the Internal Revenue Code of 1986, as amended.
Ins 3.465(2)(d) (d) "Qualifying partnership policy exchange" means the exchange of an existing long-term care insurance plan with an identical policy that on or after January 1, 2009 is certified by the insurer to meet the federal requirements established for the state's partnership program or the exchange of an existing long-term care insurance policy with an identical policy except for the addition of a benefit or rider that, on or after January 1, 2009, is certified by the insurer to meet the federal requirements established for the state's partnership program.
Ins 3.465(2)(e) (e) "Secretary" means the U. S. Secretary of the Department of Health and Human Services.
Ins 3.465(3) (3)Qualifying partnership policies.
Ins 3.465(3)(a)(a) This section applies to an insurer offering a long-term care policy that is intended to qualify an insured under the state's partnership program and that is in compliance with the requirements of 42 U.S.C 1396p (b).
Ins 3.465(3)(b) (b) In order for a long-term care policy to qualify as a qualifying partnership policy, the policy shall comply with the requirements set forth in s. 49.45 (31), Stats., and the all of the following:
Ins 3.465(3)(b)1. 1. Be filed with and approved by the commissioner prior to use and contain the certification referenced in sub. (5) (a), and comply with s. 631.28, Stats.
Ins 3.465(3)(b)2. 2. Meet the requirements of a tax-qualified long-term care insurance contract as defined in section 7702B(b) of the Internal Revenue Code of 1986, as amended.
Ins 3.465(3)(b)3. 3. Meet all applicable requirements of this section and ss. Ins 3.455 and 3.46.
Ins 3.465(3)(b)4. 4. Be accompanied by a clear disclosure that the policy is intended to be a qualifying partnership policy. The disclosure shall be in the format contained in Appendix 1.
Ins 3.465(3)(b)5. 5. Provide inflation protection provisions in compliance with sub. (5).
Ins 3.465(3)(b)6. 6. Not base underwriting criteria upon whether or not the policy is a qualifying partnership policy.
Ins 3.465(4) (4)Form requirements for qualifying partnership policies. An insurer that offers a long-term care insurance policy that is intended to qualify an insured under the state's partnership program shall comply with all of the following:
Ins 3.465(4)(a) (a) File the policy, outline of coverage, premium rates, and actuarial memorandum to the commissioner in accordance with s. 631.20, Stats., and s. Ins 3.455, and include the qualifying partnership policy certification form.
Ins 3.465 Note Note: The qualifying partnership policy certification form (OCI No. 26-113) can be obtained from the Office of the Commissioner of Insurance at no cost from the OCI website www.oci.wi.gov or by writing to the State of Wisconsin Office of the Commissioner of Insurance 125 S. Webster, Madison, WI 53703.
Ins 3.465(4)(b) (b) Submit the qualifying partnership policy certification form to the commissioner, prior to use, for approval if an insurer intends to use a previously approved policy to qualify as a qualifying partnership policy.
Ins 3.465(4)(c) (c) File the endorsement or rider and submit the qualifying partnership policy certification form to the commissioner, prior to use, for approval if the insurer intends to amend a previously approved policy with an endorsement or rider, as needed, to qualify the policy as a qualifying partnership policy.
Ins 3.465(4)(d) (d) Certification shall be in the format specified by the commissioner and identified as OCI No. 26-113, and comply with the following:
Ins 3.465(4)(d)1. 1. The certification shall be made and signed by an officer of the insurer having the authority to bind the insurer and shall include full contact information for the certifying officer.
Ins 3.465(4)(d)2. 2. The certification for pars. (b) and (c) shall identify the policy by the original form number and approval date.
Ins 3.465(5) (5)Inflation protection requirements. An insurer offering a long-term care insurance policy that is intended to qualify an insured under the state partnership program shall comply with the following inflation protection provisions.
Ins 3.465(5)(a) (a) For a person who is less than 61 years of age as of the date of purchase of the policy, the policy shall provide compound annual inflation protection that complies with one of the following:
Ins 3.465(5)(a)1. 1. Provide and maintain a level premium that contains automatic annual compounded inflation increases at a rate that is at least 3%.
Ins 3.465(5)(a)2. 2. Provide and maintain a level premium that contains automatic annual compounded inflation increases at a rate based on changes in the consumer price index.
Ins 3.465(5)(a)3. 3. Provide for annual compounded inflation increases at a rate that is at least 3% and meet all of the following requirements:
Ins 3.465(5)(a)3.a. a. Each benefit increase occurs automatically, unless the insured specifically rejects an increase.
Ins 3.465(5)(a)3.b. b. The increases shall be provided until the insured has at least attained age 76 and each increase up to and including the increase that takes effect at age 76 may not be rejected by the insured in order to retain qualifying partnership policy status.
Ins 3.465(5)(a)3.c. c. Increases may end when the insured has attained age 76, rejected an offer of inflation increase, or becomes eligible for benefits on or after age 76.
Ins 3.465(5)(a)3.d. d. The additional premium for each increase under this feature may be based on the premium rates that apply to the insured's attained age at the time of the increase.
Ins 3.465(5)(a)3.e. e. Rejection of an increase may not limit the coverage under the policy, except for the asset disregard feature of a qualified partnership policy, and from the insured receiving future premium increases as contemplated in s. Ins 3.455.
Ins 3.465(5)(b) (b) For a person who is at least 61 years of age but less than 76 years of age as of the date of purchase of the policy, the policy shall provide inflation protection that meets the requirements of par. (a) or an inflation protection feature that provides at least 3% annual simple inflation protection.
Ins 3.465(5)(c) (c) For a person who is at least 76 years of age as of the date of purchase of the policy, the policy may provide inflation protection with terms no less restrictive than those identified in pars. (a) and (b), but inflation protection is not required.
Ins 3.465(6) (6)Disclosure when soliciting. In addition to the requirements of s. Ins 3.46, an insurer issuing or marketing a policy that is intended to qualify an insured for the state's partnership program shall explain at the time of solicitation the benefits associated with a qualifying partnership policy and comply with all of the following:
Ins 3.465(6)(a)1.1. An insurer or its intermediary shall provide to each prospective applicant all of the following:
Ins 3.465(6)(a)1.a. a. Qualifying partnership policy notices in the format contained in Appendix 1 and 2.
Ins 3.465(6)(a)1.b. b. The Guide to Long-term Care booklet.
Ins 3.465(6)(a)1.c. c. The Wisconsin Long-term Care Programs guide.
Ins 3.465(6)(a)2. 2. No insurer or intermediary shall be responsible for providing applicants the revised guides until 90 days after the insurer or intermediary has been given notice that the revised guides are available.
Ins 3.465(6)(b) (b) For a qualifying partnership policy issued to a group when an outline of coverage is not delivered, the insurer or intermediary shall deliver copies of the qualifying partnership policy disclosure notice, The Guide to Long-term Care booklet, and The Wisconsin Long-term Care Programs guide.
Ins 3.465(6)(c) (c) For a life insurance policy that offers long-term care insurance as a provision in the policy or in a rider that is intended to qualify an insured under the state's partnership program, the insurer or intermediary at the time of solicitation shall deliver the disclosure notice (Appendix 1), the Guide to Long-term Care booklet, and the Wisconsin Long-term Care Programs guide.
Ins 3.465(7) (7)Other disclosures.
Ins 3.465(7)(a)(a) When an insurer is made aware that the insured or certificateholder initiated a policy change request or declined a benefit increase that will result in the loss of the status as a qualifying partnership policy, the insurer shall provide, in writing, an explanation of how such action impacts the insured. The insurer shall also advise the insured or certificateholder of how to retain the policy as a qualified partnership policy, if requested.
Ins 3.465(7)(b) (b) If a qualifying partnership policy no longer meets the requirements of the state's partnership program, the insurer shall explain, in writing, to the policyholder or certificateholder the reason for the loss of status.
Ins 3.465(7)(c) (c) The insurer shall provide a completed qualifying partnership policy summary document in the format of OCI No. 26-114, when requested by the insured or the insured's authorized representative.
Ins 3.465(8) (8)Exchange of long-term care insurance policy to a qualifying partnership policy.
Ins 3.465(8)(a)(a) Restrictions on exchange.
Ins 3.465(8)(a)1.1. Insurers offering long-term care policies that are intended to qualify an insured under the state's partnership program are subject to s. Ins 3.455 (9m).
Ins 3.465(8)(a)2. 2. Insurers issuing an automatic exchange shall comply with all of the following:
Ins 3.465(8)(a)2.a. a. Only a policy that requires no modifications or additions is eligible for an automatic exchange.
Ins 3.465(8)(a)2.b. b. The new policy may not be underwritten.
Ins 3.465(8)(a)2.c. c. The rate used in determining the premium charged for the new policy shall be determined using the original issue age and risk class of the insured that was used to determine the rate of the existing policy and may not contemplate that the new policy is a qualified partnership policy.
Ins 3.465(8)(a)2.d. d. Insurers issuing automatic exchanges shall provide insureds, at the time of notice of the automatic exchange, a copy of Appendix 1, the Guide to Long-Term Care booklet and the Wisconsin Long-Term Care Programs guide. After issuance of the notice for automatic exchange, if the insured does not decline the offer, the insurer shall provide the insured a copy of Appendix 2.
Ins 3.465(8)(a)2.e. e. Insurers issuing an automatic exchange shall offer to the insured, at the time of notice of the automatic exchange, the option to decline the automatic exchange and retain the existing policy if the insured responds within a period of time not less than 120 days.
Ins 3.465(8)(a)3. 3. An insurer offering an exchange as to a qualifying partnership policy with an actuarial value of benefits exceeding the actuarial value of benefits of the existing policy shall be subject to all of the following:
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