(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;