Ins 3.46(17)(b)
(b) A long-term care, nursing home only and home health care only policy or certificate shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits may not be more restrictive than requiring either a deficiency in the ability to perform not more than 3 of the activities of daily living or the presence of cognitive impairment.
Ins 3.46(17)(c)1.1. Activities of daily living shall include at least those contained in the definition in par.
(a).
Ins 3.46(17)(c)2.
2. Insurers may use deficiencies to perform activities of daily living to determine when covered benefits are payable in addition to those contained in par.
(a) as long as they are defined in the policy.
Ins 3.46(17)(d)
(d) An insurer may use additional provisions for the determination of when benefits are payable under a policy or certificate; however, the provisions may not restrict, and are not in lieu of, the requirements contained in pars.
(b) and
(c).
Ins 3.46(17)(e)
(e) For purposes of this section, the determination of a deficiency may not be more restrictive than any of the following:
Ins 3.46(17)(e)1.
1. Requiring hands-on assistance of another person to perform the prescribed activities of daily living.
Ins 3.46(17)(e)2.
2. If the deficiency is due to the presence of cognitive impairment, supervision or verbal cueing by another person is needed in order to protect the insured and others.
Ins 3.46(17)(f)
(f) Assessments of activities of daily living and cognitive impairment shall be performed by licensed or certified professionals, such as physicians, nurses or social workers.
Ins 3.46(17)(g)
(g) Long-term care, nursing home only and home health care only policies shall include a clear description of the process for appealing and resolving benefit determinations.
Ins 3.46 Note
Note:
The rule revision effective August 1, 1996 applies to any policy solicited, delivered or issued after September 1, 1996. After August 1, 1996 but before September 1, 1996, the insurer may market policies under either the current rule or the revised rule, if a policy form conforming to this section has been approved.
Ins 3.46(18)
(18)
Tax qualified long term care, nursing home and home health care policies. This subsection applies to long term care, nursing home or home health care policies which are intended to be tax qualified under and comply with the requirements of section
7702B of the Internal Revenue Code of 1986, as amended, and any regulations and administrative pronouncements issued under the Code.
Ins 3.46(18)(a)
(a) In order to qualify for certain tax treatment, long term care, nursing home only and home health care only policy provisions may contain the following conditions as defined in section
7702B of the Internal Revenue Code of 1986 as amended and any regulations and administrative pronouncements issued thereunder notwithstanding sub.
(17):
Ins 3.46(18)(a)1.
1. The terms “severe cognitive impairment” and “substantial supervision" may be used in lieu of the term “cognitive impairment" and its accompanying supervision requirement may be used as a benefit trigger in sub.
(17) (a) 3. and
(e) 2. Ins 3.46(18)(a)3.
3. The requirement that the claimant obtain a certification from a licensed health care practitioner, as defined in section
7702B of the Internal Revenue Code of 1986, as amended, and any regulations and administrative pronouncements issued under the Code, as a condition for claim payment that the functional incapacity or inability to perform at least 2 activities of daily living triggering benefits under the policy is expected to last at least 90 days, may be imposed by the insurer.
Ins 3.46(18)(b)
(b) The policy shall contain a clear disclosure that the policy is intended to be a tax qualified long term care policy.
Ins 3.46(18)(c)
(c) The outline of coverage shall prominently disclose that, in order to meet the requirements of a tax qualified policy, the functional incapacity or inability to perform activities of daily living triggering benefits under the policy must be expected to last for at least 90 days.
Ins 3.46(18)(d)
(d) All other applicable provisions in this section or s.
Ins 3.455 shall continue to apply to tax qualified long term care, nursing home and home health care policies.
Ins 3.46(19)
(19)
Nonforfeiture benefit requirements for long-term care. Ins 3.46(19)(a)(a) No insurer may advertise, market or offer a long–term care, nursing home only or home health care only policy or certificate unless the insurer offers, at the time of sale, a shortened benefit period nonforfeiture benefit.
Ins 3.46(19)(b)
(b) If the offer required to be made under par.
(a) is rejected, the insurer shall provide the contingent benefit upon lapse described in this section.
Ins 3.46(19)(c)1.1. After rejection of the offer required under par.
(a) for individual and group policies without nonforfeiture benefits issued after the effective date of this subsection, the insurer shall provide a contingent benefit upon lapse.
Ins 3.46(19)(c)2.
2. If a group policyholder elects to make the nonforfeiture benefit an option to the certificateholder, a certificate shall provide either the nonforfeiture benefit or the contingent benefit upon lapse.
Ins 3.46(19)(c)3.
3. The contingent benefit on lapse shall be triggered every time an insurer increases the premium rates to a level which results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth in the table in the subdivision based on the insured's issue age, and the policy or certificate lapses within 120 days of the due date of the premium so increased. Unless otherwise required, policyholders shall be notified at least 60 days prior to the due date of the premium reflecting the rate increase.
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See PDF for table 
Ins 3.46(19)(c)4.
4. On or before the effective date of a substantial premium increase as described in subd.
3. the insurer shall do all of the following:
Ins 3.46(19)(c)4.a.
a. Offer to reduce policy benefits provided by the current coverage without the requirement of additional underwriting so that required premium payments are not increased.
Ins 3.46(19)(c)4.b.
b. Offer to convert the coverage to a paid-up status where the amount payable for each benefit is 90% of the amount payable in effect immediately prior to lapse times the ratio of the number of completed months of paid premiums divided by the number of months in the premium paying period. This option may be elected at any time during the 120-day period referenced in subd.
3. Ins 3.46(19)(c)4.c.
c. Notify the policyholder or certificateholder that a default or lapse at any time during the 120-day period referenced in subd.
3. shall be deemed to be the election of the offer to convert in subd.
4. b., if the ratio is 40% or more.
Ins 3.46(19)(d)
(d) The required benefits continued as nonforfeiture benefits under par.
(a), including contingent benefits upon lapse under par.
(b), are computed as follows:
Ins 3.46(19)(d)1.
1. “Attained age rating" as applied in this paragraph is defined as a schedule of premiums starting from the issue date which increases with age at least 1% per year prior to age 50, and at least 3% per year for age 50 and beyond.
Ins 3.46(19)(d)2.
2. The nonforfeiture benefit shall provide paid-up long-term care, nursing home only or home care only insurance coverage after lapse. The amounts and frequency of benefits in effect at the time of lapse, but not increased thereafter, shall be payable for a qualifying claim, but the lifetime maximum dollars or days of benefits shall be determined as specified in subd.
3. Ins 3.46(19)(d)3.
3. The standard nonforfeiture credit shall be at least 100% of the sum of all premiums paid, including the premiums paid prior to any changes in benefits. The insurer may offer additional shortened benefit period options, as long as the benefits for each duration equal or exceed the standard nonforfeiture credit for that duration. However, the minimum nonforfeiture credit may not be less than 30 times the daily nursing home benefit at the time of lapse. In either event, the calculation of the nonforfeiture credit is subject to the limitation of par.
(e).
Ins 3.46(19)(d)4.
4. The nonforfeiture benefit shall begin not later than the end of the third year following the policy or certificate issue date. The contingent benefit upon lapse shall be effective during the first 3 years and subsequent years. For a policy or certificate with attained age rating, the nonforfeiture benefit shall begin on the earlier of end of the tenth year following the policy or certificate issue date or of the end of the second year following the date the policy or certificate is no longer subject to attained age rating.
Ins 3.46(19)(d)5.
5. Nonforfeiture credits may be used for all care and services qualifying for benefits under the terms of the policy or certificate, up to the limits specified in the policy or certificate.
Ins 3.46(19)(e)
(e) All benefits paid by the insurer while the policy or certificate is in premium–paying status and in the paid-up status may not exceed the maximum benefits which would have been payable if the policy or certificate had remained in premium-paying status.
Ins 3.46(19)(f)
(f) There shall be no difference in the minimum nonforfeiture benefits as required under this subsection for group and individual policies.
Ins 3.46(19)(g)
(g) Premiums charged for a policy or certificate containing nonforfeiture benefits shall be subject to the loss ratio requirements contained in s.
Ins 3.455 (5) treating the policy as a whole.
Ins 3.46(19)(h)1.
1. Except as provided in subd.
2., the provisions of this subsection apply to any long-term care, nursing home, and home health care policy issued in this state on or after January 1, 2002.
Ins 3.46(19)(h)2.
2. For group long-term care, nursing home, and home health care insurance certificates issued to employer-sponsored groups or labor organizations in this state and in force on or after January 1, 2002, which policy was in force on January 1, 2001, the provisions of this subsection shall not apply.
Ins 3.46(19)(i)
(i) To determine whether contingent nonforfeiture upon lapse provisions are triggered under par.
(c) 3. a replacing insurer that purchased or otherwise assumed a block or blocks of long-term care insurance policies from another insurer shall calculate the percentage increase based on the initial annual premium paid by the insured when the policy was first purchased from the original insurer.
Ins 3.46(19)(j)
(j) A contingent benefit on lapse shall also be triggered for policies with a fixed or limited premium paying period every time an insurer increases the premium rates to a level that results in a cumulative increase of the annual premium equal to or exceeding the percentage of the insured's initial annual premium set forth in par.
(c) 3. based on the insured's issue age, the policy or certificate lapses within 120 days of the due date of the premium so increased, and the ratio is 40% or more. Unless otherwise required, policyholders shall be notified at least 30 days prior to the due date of the premium reflecting the rate increase.
Ins 3.46(20)
(20)
Incontestability period. An insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim only as permitted under ss.
631.11 (1) (b) and
632.76, Stats., and only if in addition to complying with ss.
631.11 (1) (b) and
632.76, Stats., any of the following apply:
Ins 3.46(20)(a)
(a) For a policy or certificate that has been in force for less than 6 months, the insurer shows the misrepresentation is material to the acceptance for coverage.
Ins 3.46(20)(b)
(b) For a policy or certificate that has been in force for at least 6 months but less than 2 years, the insurer shows the misrepresentation is both material to the acceptance for coverage and pertains to the condition for which benefits are sought.
Ins 3.46(20)(c)
(c) For a policy or certificate that has been in force 2 years or more, the insurer shows that the insured knowingly, intentionally and fraudulently misrepresented relevant facts relating to the insured's health.
Ins 3.46(20)(d)1.1. No long-term care insurance policy or certificate may be field issued based on medical or health status unless the compensation to the field issuer is not based on the number of policies or certificates issued.
Ins 3.46(20)(d)2.
2. For purposes of this paragraph, a policy or certificate that is “field issued" means the producer or third-party administrator using the insurer's underwriting guidelines underwrites the policy not the insurer, pursuant to the authority granted to the producer or third-party administrator by an insurer.
Ins 3.46(20)(e)
(e) If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.
Ins 3.46(20)(f)
(f) In the event of the death of the insured, this subdivision may not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by s.
632.46, Stats. In all other situations, this subdivision shall apply to life insurance policies that accelerate benefits for long-term care.
Ins 3.46(21)(a)(a) Every insurer shall maintain records for each intermediary of that intermediary's amount of replacement sales as a percent of the intermediary's total annual sales and the amount of lapses of long-term care insurance policies sold by the intermediary as a percent of the intermediary's total annual sales.
Ins 3.46(21)(b)
(b) Every insurer shall report annually by June 30 the 10% of its intermediaries with the greatest percentages of lapses and replacements as measured by par.
(a) using Appendix 10.
Ins 3.46(21)(c)
(c) Reported replacement and lapse rates do not alone constitute a violation of insurance laws or necessarily imply wrongdoing. The reports are for the purpose of reviewing more closely intermediary activities regarding the sale of long-term care insurance.
Ins 3.46(21)(d)
(d) Every insurer shall report annually by June 30 the number of lapsed policies as a percent of its total annual sales and as a percent of its total number of policies in force as of the end of the preceding calendar year using Appendix 10.
Ins 3.46(21)(e)
(e) Every insurer shall report annually by June 30 the number of replacement policies sold as a percent of its total annual sales and as a percent of its total number of policies in force as of the preceding calendar year using Appendix 10.
Ins 3.46(21)(f)
(f) Every insurer shall report annually by June 30, for qualified long-term care insurance contracts, the number of claims denied for each class of business, expressed as a percentage of claims denied using Appendix 9.
Ins 3.46(22)
(22)
Filing requirements for advertising. Every insurer, health care service plan or other entity providing long-term care insurance or benefits in this state shall provide a copy of any long-term care insurance advertisement whether through written, radio or television medium to the commissioner as required by s.
Ins 3.27. In addition, all advertisements shall be retained by the insurer, health care service plan or other entity for at least 3 years from the date the advertisement was first used.
Ins 3.46(23)(a)(a) Every insurer or other entity marketing long-term care insurance coverage in this state, directly or through its intermediaries, shall do all of the following:
Ins 3.46(23)(a)1.
1. Establish marketing procedures and intermediary training requirements to assure that both of the following are met:
Ins 3.46(23)(a)1.a.
a. Any marketing activities, including any comparison of policies, by its intermediaries or other producers will be fair and accurate.
Ins 3.46(23)(a)2.
2. Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy the following notice:
“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(23)(a)3.
3. Provide copies of the disclosure forms required in Appendices 2 and 3 to the applicant.
Ins 3.46(23)(a)4.
4. Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for long-term care insurance already has accident and sickness or long-term care insurance and the types and amounts of any such insurance, except that in the case of qualified long-term care insurance contracts as defined in s.
Ins 3.465 (2) (d), an inquiry into whether a prospective applicant or enrollee for long-term care insurance has accident and sickness insurance is not required.
Ins 3.46(23)(a)5.
5. Every insurer or entity marketing long-term care insurance shall establish auditable procedures for verifying compliance with this paragraph.
Ins 3.46(23)(a)6.
6. If the state in which the policy or certificate is to be delivered or issued for delivery has a senior insurance counseling program, the insurer shall, at solicitation, provide written notice to the prospective policyholder and certificateholder that the program is available and the name, address and telephone number of the program.
Ins 3.46(23)(a)7.
7. For long-term care insurance policies and certificates, use the terms “noncancellable" or “level premium" only when the policy or certificate conforms with sub.
(3) (f).
Ins 3.46(23)(a)8.
8. Provide an explanation of contingent benefit upon lapse provided for in sub.
(19) (c), and, if applicable, the additional contingent benefit upon lapse provided to policies with fixed or limited premium paying periods in sub.
(15) (e).
Ins 3.46(23)(b)
(b) In addition to the practices prohibited in s.
628.34 (12), Stats., the following acts and practices are prohibited by insurers or other entities marketing long-term care insurance coverage in this state, directly or through its intermediaries:
Ins 3.46(23)(b)1.
1. “Twisting." Knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer.
Ins 3.46(23)(b)2.
2. “High pressure tactics." Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.
Ins 3.46(23)(b)3.
3. “Cold lead advertising." Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company.
Ins 3.46(23)(b)4.
4. “Misrepresentation." Misrepresenting a material fact in selling or offering to sell a long-term care insurance policy.
Ins 3.46(23)(c)
(c) In regards to any transaction involving a long-term care insurance product, no person subject to regulation under chs.
600 to
655, Stats., may knowingly prevent or dissuade or attempt to prevent or dissuade, any person from any of the following:
Ins 3.46(23)(c)1.
1. Filing a complaint with the office of the commissioner of insurance.
Ins 3.46(23)(c)2.
2. Cooperating with the office of the commissioner of insurance in any investigation.
Ins 3.46(23)(c)3.
3. Attending or giving testimony at any proceeding authorized by law.
Ins 3.46(23)(d)
(d) If an insured exercises the right to return a policy during the free-look period, the issuer shall mail the entire premium refund directly to the person who paid the premium.
Ins 3.46(23)(e)1.1. With respect to the obligations set forth in this subsection, the primary responsibility of an association, as described in s.
600.01 (1) (b) 3., Stats., when endorsing or selling long-term care insurance shall be to educate its members concerning long-term care issues in general so that its members can make informed decisions. Associations shall provide objective information regarding long term care insurance policies or certificates endorsed or sold by such associations to ensure that members of such associations receive a balanced and complete explanation of the features in the policies or certificates that are being endorsed or sold.
Ins 3.46(23)(e)2.
2. The insurer shall file with the office of the commissioner of insurance all of the following material:
